Parent-Child Nursing Set 3-2 (Chapters 23, 24, 38, and 44)

17. After teaching the parents of a newborn with retinopathy of prematurity (ROP) about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?" B) "We can fix the problem with surgery." C) "We'll make sure to administer eye drops each day for the next few weeks." D) "I'm sure the baby will grow out of it."

A) "Can we schedule follow-up eye examinations with the pediatric ophthalmologist now?" Ans: A Feedback: Parents of a newborn with suspected retinopathy of prematurity (ROP) should schedule follow-up vision screenings with a pediatric ophthalmologist every 2 to 3 weeks, depending on the severity of the findings at the initial examination. Page and Header: 1450 (CH.39), Nursing Management

9. The nurse is caring for a child with a spinal cord injury and providing instruction to the parents on promoting skin integrity. Which response from the mother indicates a need for further teaching? A) "I need to monitor his skin at least twice a week." B) "I must monitor skin affected by his adaptive equipment." C) "He must change positions frequently." D) "We must avoid harsh cleaning products."

A) "I need to monitor his skin at least twice a week." Ans: A Feedback: The nurse needs to emphasize to the mother that she must monitor the condition of the entire surface of the skin several times daily to provide a baseline and allow for early identification of areas at risk. Monitoring the skin affected by adaptive equipment, changing positions frequently, and avoiding harsh cleaning products are appropriate. Page and Header: 1722, Nursing Diagnoses, Goals, Interventions, and Evaluations, Nursing Care Plan 44.1

3. The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate? A) "I will help you become comfortable in caring for your daughter." B) "You must learn how to care for your daughter at home." C) "You will need to learn to collaborate with all the caregivers." D) "There is a lot to learn, and you need a positive attitude."

A) "I will help you become comfortable in caring for your daughter." Ans: A Feedback: The nurse needs to empower families to become the experts on their child's needs and conditions via education and participation in care. The most positive approach is to let the mother know the nurse will support her and help her become an expert on her daughter's care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is true, but does not address her fears. Page and Header: 1696, Educating and Supporting the Child and Family

13. A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching? A) "We should give this drug before he eats anything." B) "We need to keep a close eye for possible infection." C) "The drug should not be stopped suddenly." D) "He might gain some weight with this drug."

A) "We should give this drug before he eats anything." Ans: A Feedback: Corticosteroids such as prednisone can cause gastric upset, so the medication should be given with food to reduce this risk. The drug may mask the signs of infection, so the parents need to monitor the child closely for any changes. Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. Common side effects of this drug include weight gain, osteoporosis, and mood changes. Page and Header: 1677, Common Medical Treatments, Drug Guide 44.1

7. An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting symptoms of hypoglycemia. Which of the following would the nurse do next? A) Administer intravenous glucose immediately. B) Feed the newborn 2 ounces of formula. C) Initiate blow-by oxygen therapy. D) Place the newborn under a radiant warmer.

A) Administer intravenous glucose immediately. Ans: A Feedback: If an LGA newborn's blood glucose level is below 40 mg/dL and is symptomatic, continuous infusion of parenteral glucose is needed. Supervised breast-feeding or formula feeding may be initial treatment options in asymptomatic hypoglycemia. Blow-by oxygen would have no effect on glucose levels; it may be helpful in promoting oxygenation. Placing the newborn under a radiant warmer would be a more appropriate measure for cold stress. Page and Header: 878-880, Nursing Management, Table 23.1

27. A 10-month-old is brought to the emergency department by her parents after they found her face down in the bathtub. The mother said, "I just left the bathroom to answer the phone. When I came back, I found her." Which of the following assessments would be the priority? A) Airway, breathing, and circulation B) Level of consciousness C) Vital signs D) Pupillary response

A) Airway, breathing, and circulation Ans: A Feedback: With a submersion injury, hypoxia is the primary problem. Therefore, assessment of airway, breathing, and circulation are the priority assessments for which the nurse would institute resuscitative measures. Other assessments such as level of consciousness, vital signs, and papillary response would be done once the child's airway, breathing, and circulation are assessed and emergency interventions are instituted. Page and Header: 1419, Nursing Assessment

25. A nurse is developing a plan of care for a preterm newborn to address the nursing diagnosis of risk for delayed development. Which of the following would the nurse include? (Select all that apply.) A) Clustering care to promote rest B) Positioning newborn in extension C) Using kangaroo care D) Loosely covering the newborn with blankets E) Providing nonnutritive sucking

A) Clustering care to promote rest C) Using kangaroo care E) Providing nonnutritive sucking Ans: A, C, E Feedback: The nurse would focus the plan of care on developmental care, which includes clustering care to promote rest and conserve energy, using flexed positioning to simulate in utero positioning, using kangaroo care to promote skin to skin sensations, swaddling with a blanket to maintain the flexed position, and providing nonnutritive sucking. Page and Header: 893, Promoting Growth and Development

22. A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which of the following? Select all answers that apply. A) Complaints of stiff neck B) Photophobia C) Absent headache D) Negative Brudzinski sign E) Vomiting

A) Complaints of stiff neck B) Photophobia E) Vomiting Ans: A, B, E Feedback: In addition to the adolescent's complaints and history, other findings suggesting bacterial meningitis include complaints of a stiff neck, photophobia, headache, positive Brudzinski sign, and vomiting. Page and Header: 1409, Health History

22. A nurse is explaining to the parents of a child with bladder exstrophy about the care their infant requires. Which of the following would the nurse include in the explanation? (Select all that apply.) A) Covering the area with a sterile, clear, nonadherent dressing B) Irrigating the surface with sterile saline twice a day C) Monitoring drainage through the suprapubic catheter D) Administering prescribed antibiotic therapy E) Preparing for surgical intervention in about 2 weeks

A) Covering the area with a sterile, clear, nonadherent dressing C) Monitoring drainage through the suprapubic catheter D) Administering prescribed antibiotic therapy Ans: A, C, D Feedback: Care for an infant with bladder exstrophy includes covering the area with a sterile, clear, nonadherent dressing and irrigating the bladder surface with sterile saline after each diaper change to prevent infection, assisting with insertion and monitoring drainage from suprapubic catheter, administering prescribed antibiotic therapy, and preparing the parents and infant for surgery within 48 hours after birth. Page and Header: 948, Bladder Exstrophy

19. After determining that a newborn is in need of resuscitation, which of the following would the nurse do first? A) Dry the newborn thoroughly B) Suction the airway C) Administer ventilations D) Give volume expanders

A) Dry the newborn thoroughly Ans: A Feedback: If resuscitation is need, the nurse must first stabilize the newborn by drying the newborn thoroughly with a warm towel and provide warmth by placing him or her under a radiant heater to prevent rapid heat loss. Next the newborn's head is placed in a neutral position to open the airway and the airway is cleared with a bulb syringe or suction catheter. Breathing is stimulated. Often handling and rubbing the newborn with a dry towel may be all that is needed to stimulate respirations. Next ventilations and then chest compressions are done. Administration of epinephrine and/or volume expanders is the last step. Page and Header: 887 Resuscitating the Newborn

Chapter 24- Nursing Management of the Newborn at Risk Maternity and Pediatric Nursing 1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which of the following would the nurse anticipate as possibly necessary for this newborn? A) Extracorporeal membrane oxygenation (ECMO) B) Respiratory support with a ventilator C) Insertion of a laryngoscope for deep suctioning D) Replacement of an endotracheal tube via x-ray

A) Extracorporeal membrane oxygenation (ECMO) Ans: A Feedback: If conventional measures are ineffective, then the nurse would need to prepare the newborn for ECMO. Hyperoxygenation, ventilatory support, and suctioning are typically used initially to promote tissue perfusion. However, if these are ineffective, ECMO would be the next step. Page and Header: 916, Nursing Management

10. A 4-year-old boy has a history of seizures and has been started on a ketogenic diet. Which of the following food selections would be most appropriate for his lunch? A) Fried eggs, bacon, and iced tea B) A hamburger on a bun, French fries, and milk C) Spaghetti with meatballs, garlic bread, and a cola drink D) A grilled cheese sandwich, potato chips, and a milkshake

A) Fried eggs, bacon, and iced tea Ans: A Feedback: The ketogenic diet involves a high intake of fats, adequate protein intake, and a very low intake of carbohydrates, resulting in a state of ketosis. The child is kept in a mild state of dehydration. Eggs and bacon are high in fat; the tea does not contain any carbohydrates. Therefore, this is the best choice. The hamburger is fat and protein, the bun is a carbohydrate, and the French fries and the milk both contain fat and protein, but both contain a lot of carbohydrates. The pasta and the sauce for the spaghetti are carbohydrates, the meatballs are protein, and the garlic bread is a carbohydrate, as is the cola drink. The grilled cheese sandwich has the fat and protein from the cheese, but the bread and chips are primarily carbohydrates, and the milkshake has fat, protein, and carbohydrates. Only the selection in A contains a ketogenic meal. Page and Header: 1383 & 1393, Therapeutic Management, Common Medical Treatments 38.1

23. The nurse is assessing a preterm newborn who is in the neonatal intensive care unit (NICU) for signs and symptoms of overstimulation. Which of the following would the nurse be least likely to assess? A) Increased respirations B) Flaying hands C) Periods of apnea D) Decreased heart rate

A) Increased respirations Ans: A Feedback: Conversely, overstimulation may have negative effects by reducing oxygenation and causing stress. A newborn reacts to stress by flaying the hands or bringing an arm up to cover the face. When overstimulated, such as by noise, lights, excessive handling, alarms, and procedures, and stressed, heart and respiratory rates decrease and periods of apnea or bradycardia may occur. Page and Header: 891, Providing Appropriate Stimulation

3. The nurse is caring for a child hospitalized with Reye syndrome who is in the acute stage of the illness. The nurse would assess the child most carefully for which of the following? A) Indications of increased intracranial pressure B) An increase in the blood glucose level C) A decrease in the liver enzymes D) A presence of protein in the urine

A) Indications of increased intracranial pressure Ans: A Feedback: Reye syndrome is characterized by brain swelling, liver failure, and death in hours if treatment is not initiated. Therefore, increased intracranial pressure could occur. Liver enzyme levels typically increase. Blood glucose levels and protein in the urine are not characteristic of this illness. Page and Header: 1413, Nursing Assessment

25. A group of students are reviewing information about head injuries in children. The students demonstrate understanding of this information when they identify which of the following as the most common type of skull fracture in children? A) Linear B) Depressed C) Diastatic D) Basilar

A) Linear Ans: A Feedback: The most common type of skull fracture in children is a linear skull fracture, which can result from minor head injuries. Other, less common types of skull fractures in children include depressed, diastatic, and basilar. Page and Header: 1414, Table 38.7

4. The physician has ordered rectal diazepam (Valium) for a 2-year-old boy with status epilepticus. Which of the following instructions is essential for the nurse to teach the parents? A) Monitor their child's level of sedation. B) Watch for fever indicating infection. C) Gradually reduce the dosage as seizures stop. D) Monitor for an allergic reaction to the medication.

A) Monitor their child's level of sedation. Ans: A Feedback: Diazepam is useful for home management of prolonged seizures and requires that the parents be educated on its proper administration. Monitoring the child's level of sedation is key when giving diazepam because it slows the central nervous system. Parents need to monitor the overall health of the child, including temperature when needed, but that has nothing to do with the diazepam. When the use of an anticonvulsant is stopped, gradual reduction of the dosage is necessary to prevent seizures or status epilepticus. This is not done without a physician's order. Monitoring for allergic reactions is necessary when any medications have been prescribed, but is not specific to diazepam. Page and Header: 1384, Common Medical Treatments, Drug Guide 38.1

17. A nurse is preparing a school-aged child for a lumbar puncture. The nurse would expect to position the child in which manner? A) On her side with the head flexed forward and knees flexed to the abdomen B) Sitting upright with the head flexed forward to the chest C) Supine with arms and legs pronated and extended D) Prone with the arms flexed under the chest

A) On her side with the head flexed forward and knees flexed to the abdomen Ans: A Feedback: When a lumbar puncture is performed on a child, the child is placed on his or her side with the head flexed forward and knees flexed to the abdomen. An infant would be positioned sitting upright with the head flexed forward. A supine position with the arms and legs pronated and extended suggests decerebrate posturing. A prone position is not used for a lumbar puncture. Page and Header: 1391, Common Laboratory and Diagnostic Tests 38.1/Figure 38.6

11. A child with increased intracranial pressure is being treated with hyperventilation. The nurse understands the need for this treatment is based on which of the following? A) PaCO2 levels decrease, causing vasoconstriction. B) Drainage of cerebrospinal fluid occurs. C) Activity is controlled via a stimulator. D) Hyperexcitability of the nerves is reduced.

A) PaCO2 levels decrease, causing vasoconstriction. Ans: A Feedback: Hyperventilation decreases PaCO2, which results in vasoconstriction and therefore decreases intracranial pressure. A shunt would allow for drainage of cerebrospinal fluid. A vagal nerve stimulator is used to provide an appropriate dose of stimulation to manage seizure activity. Anticonvulsants decrease the hyperexcitability of nerves. Page and Header: 1383, Common Medical Treatments 38.1

21. A nurse is developing a plan of care for a newborn with omphalocele. Which of the following would the nurse include? A) Placing the newborn into a sterile drawstring bowel bag B) Using clean technique for dressing changes C) Preparing the newborn for incision and drainage D) Instituting gavage feedings

A) Placing the newborn into a sterile drawstring bowel bag Ans: A Feedback: An infant with an omphalocele is placed in a sterile drawstring bowel bag that maintains a sterile environment for the exposed contents, allows visualization, reduces heat and moisture loss, and allows heat from radiant warmers to reach the newborn. The newborn is placed feet-first into the bag and the drawstring is secured around the torso. Strict sterile technique is necessary to prevent contamination of the exposed abdominal contents. An orogastric tube attached to low suction is used to prevent intestinal distention. IV therapy is administered to maintain fluid and electrolyte balance and provide a route for antibiotic therapy. Surgery is done to repair the defect, not incise and drain it. Page and Header: 946, Nursing Management

10. When planning the care for an SGA newborn, which action would the nurse determine as a priority? A) Preventing hypoglycemia with early feedings B) Observing for respiratory distress syndrome C) Promoting bonding between the parents and the newborn D) Monitoring vital signs every 2 hours

A) Preventing hypoglycemia with early feedings Ans: A Feedback: With the loss of the placenta at birth, the newborn must now assume control of glucose homeostasis. This is achieved by early oral intermittent feedings. Observing for respiratory distress, promoting bonding, and monitoring vital signs, although important, are not the priority for this newborn. Page and Header: 876, Nursing Management

23. The nurse is assessing a child who is suspected of having Guillain-Barré syndrome. Which assessment findings would the nurse correlate as supporting this diagnosis? Select all answers that apply. A) Recent cytomegalovirus infection B) Hyperactive deep tendon reflexes C) Numbness in the lower extremities D) Sustained clonus E) Difficulty swallowing

A) Recent cytomegalovirus infection C) Numbness in the lower extremities D) Sustained clonus Ans: A, C, D Feedback: Guillain-Barré syndrome is often preceded by a viral or bacterial infection such as cytomegalovirus infection. Deep tendon reflexes are usually decreased or absent. Typically the disorder begins with muscle weakness and paresthesias such as numbness and tingling. Difficulty swallowing also may be present. Sustained clonus is more commonly associated with cerebral palsy. Page and Header: 1864, Health History

12. While reviewing a newborn's medical record, the nurse notes that the chest x-ray shows a ground glass pattern. The nurse interprets this as indicative of: A) Respiratory distress syndrome B) Transient tachypnea of the newborn C) Asphyxia D) Persistent pulmonary hypertension

A) Respiratory distress syndrome Ans: A Feedback: The chest x-ray of a newborn with RDS reveals a reticular (ground glass) pattern. For TTN, the chest x-ray shows lung overaeration and prominent perihilar interstitial markings and streakings. A chest x-ray for asphyxia would reveal possible structural abnormalities that might interfere with respiration, but the results are highly variable. An echocardiogram would be done to evaluate persistent pulmonary hypertension. Page and Header: 909, Laboratory and Diagnostic Testing

9. While caring for a preterm newborn receiving oxygen therapy, the nurse monitors the oxygen therapy duration closely based on the understanding that the newborn is at risk for which of the following? A) Retinopathy of prematurity B) Metabolic acidosis C) Infection D) Cold stress

A) Retinopathy of prematurity Ans: A Feedback: Oxygen therapy has been linked the pathogenesis of retinopathy of prematurity and is associated with the duration of oxygen use rather than the concentration of oxygen. Therefore, the nurse monitors the newborn's oxygen therapy closely. Metabolic acidosis may occur due to anaerobic metabolism used for heat production. Infection may occur for numerous reasons, but they are unrelated to oxygen therapy. Cold stress results from problems due to the preterm newborn's inadequate supply of brown fat, decreased muscle tone, and large body surface area. Page and Header: 887, Administering Oxygen

21. A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurse's suspicion? (Select all that apply.) A) Shallow, slow respirations B) Cyanotic hands and feet C) Irritability D) Hypertonicity E) Feeble cry

A) Shallow, slow respirations B) Cyanotic hands and feet E) Feeble cry Ans: A, B, E Feedback: Typically, a preterm newborn that is having problems with thermal regulation is cool to cold to the touch. The hands, feet, and tongue may appear cyanotic. Respirations are shallow or slow, or signs of respiratory distress are present. The newborn is lethargic and hypotonic, feeds poorly, and has a feeble cry. Blood glucose levels are probably low, leading to hypoglycemia, due to the energy expended to keep warm. Page and Header: 889, Maintaining Thermal Regulation

5. Which action would be most appropriate for the nurse to take when a newborn has an unexpected anomaly at birth? A) Show the newborn to the parents as soon as possible while explaining the defect. B) Remove the newborn from the birthing area immediately. C) Inform the parents that there is nothing wrong at the moment. D) Tell the parents that the newborn must go to the nursery immediately.

A) Show the newborn to the parents as soon as possible while explaining the defect. Ans: A Feedback: When an anomaly is identified at or after birth, parents need to be informed promptly and given a realistic appraisal of the severity of the condition, the prognosis, and treatment options so that they can participate in all decisions concerning their child. Removing the newborn from the area or telling them that the newborn needs to go to the nursery immediately is inappropriate and would only add to the parents' anxieties and fears. Telling them that nothing is wrong is inappropriate because it violates their right to know. Page and Header: 943, Congenital Conditions

11. When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely? A) Skeletal traction B) Physical therapy C) Orthotics D) Occupational therapy

A) Skeletal traction Ans: A Feedback: Skeletal traction would be the least likely treatment for a child with cerebral palsy. Physical therapy, orthotics and braces, and occupational therapy are all common treatments used for cerebral palsy. Page and Header: 1713, Therapeutic Management

18. The nurse is assessing the neuromusculoskeletal system of a newborn. Which of the following would the nurse identify as an abnormal finding? A) Sluggish deep tendon reflexes B) Full range of motion in extremities C) Absence of hypotonia D) Lack of purposeful muscular control

A) Sluggish deep tendon reflexes Ans: A Feedback: Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months. Sluggish deep tendon reflexes indicate an abnormality. The newborn is capable of spontaneous movement but lacks purposeful control. Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone; hypertonia or hypotonia is an abnormal finding. Page and Header: 1673, Muscular Development

20. A nurse is developing a plan of care for a preterm infant experiencing respiratory distress. Which of the following would the nurse be least likely to include in this plan? A) Stimulate the infant with frequent handling. B) Keep the newborn in a warmed isolette. C) Administer oxygen using an oxygen hood. D) Give gavage or continuous tube feedings.

A) Stimulate the infant with frequent handling. Ans: A Feedback: For the preterm infant experiencing respiratory distress, the nurse would expect to handle the newborn as little as possible to reduce oxygen requirements. Other appropriate interventions include keeping the infant warm, preferably in a warmed isolette to conserve the baby's energy and prevent cold stress; administer oxygen using an oxygen hood; and provide energy through calories via intravenous dextrose or gavage or continuous tube feedings to prevent hypoglycemia. Page and Header: 888, Administering Oxygen

24. A nurse is preparing a presentation for a local health fair about meningitis and has developed a display that lists the following causes: Streptococcus group B Haemophilus influenzae type B Streptococcus pneumoniae Neisseria meningitidis Which of these would the nurse highlight as the most common cause of meningitis in newborns? A) Streptococcus group B B) Haemophilus influenzae type B C) Streptococcus pneumoniae D) Neisseria meningitides

A) Streptococcus group B Ans: A Feedback: Meningitis due to Streptococcus group B along with Escherichia coli is most common in newborns and infants. H. influenzae type B is a common cause in infants between the ages of 6 and 9 months. S. pneumoniae and N. meningitides are common causes in children older than 3 months and in adults. Page and Header: 1409, Table 38.6

18. A nursing instructor is describing common problems associated with preterm birth. When describing the preterm newborn's risk for perinatal asphyxia, the instructor includes which of the following as contributing to the newborn's risk? (Select all that apply.) A) Surfactant deficiency B) Placental deprivation C) Immaturity of the respiratory control centers D) Decreased amounts of brown fat E) Depleted glycogen stores

A) Surfactant deficiency C) Immaturity of the respiratory control centers Ans: A, C Feedback: Preterm newborns are at risk for perinatal asphyxia due to surfactant deficiency, unstable chest wall, immaturity of the respiratory control centers, small respiratory passages, and inability to clear mucus from the airways. Placental deprivation places the postterm newborn at risk for perinatal asphyxia. Decreased amounts of brown fat and depleted glycogen stores place the SGA newborn at risk for problems with thermoregulation. Page and Header: 883, Nursing Assessment

20. The nurse is assessing a newborn and suspects that the newborn was exposed to drugs in utero because the newborn is exhibiting signs of neonatal abstinence syndrome. Which of the following would the nurse expect to assess? (Select all that apply.) A) Tremors B) Diminished sucking C) Regurgitation D) Shrill, high-pitched cry E) Hypothermia F) Frequent sneezing

A) Tremors C) Regurgitation D) Shrill, high-pitched cry F) Frequent sneezing Ans: A, C, D, F Feedback: Signs and symptoms of neonatal abstinence syndrome include tremors, frantic sucking, regurgitation or projectile vomiting, shrill high-pitched cry, fever, and frequent sneezing. Page and Header: 933, Nursing Assessment, Box 24.4

16. A nurse is assessing a newborn who has been classified as small for gestational age. Which of the following would the nurse expect to find? (Select all that apply.) A) Wasted extremity appearance B) Increased amount of breast tissue C) Sunken abdomen D) Adequate muscle tone over buttocks E) Wide skull sutures

A) Wasted extremity appearance C) Sunken abdomen E) Wide skull sutures Ans: A, C, E Feedback: Typical characteristics of SGA newborns include a head that is disproportionately large compared to the rest of the body, wasted appearance of the extremities, reduced subcutaneous fat stores, decreased amount of breast tissue, scaphoid abdomen, wide skull sutures, poor muscle tone over buttocks and cheeks, loose and dry skin appearing oversized, and a thin umbilical cord. Page and Header: 876, Nursing Assessment

27. A newborn was diagnosed with a congenital heart defect and will undergo surgery at a later time. The nurse is teaching the parents about signs and symptoms that need to be reported. The nurse determines that the parents have understood the instructions when they state that they will report which of the following? (Select all that apply.) A) Weight loss B) Pale skin C) Fever D) Absence of edema E) Increased respiratory rate

A) Weight loss C) Fever E) Increased respiratory rate Ans: A, C, E Feedback: Signs and symptoms that need to be reported include weight loss, poor feeding, cyanosis, breathing difficulties, irritability, increased respiratory rate, and fever. Page and Header: 1557 (CH.41), Nursing Management

24. A child with myasthenia gravis is brought to the emergency department by his parents. The parents have noticed a sudden increase in respiratory difficulty. The nurse suspects myasthenic crisis based on which statement by the parents? A) "We gave him an extra dose of his medication earlier today." B) "He was coughing and had a slight fever yesterday and today." C) "Things have been pretty stress-free lately." D) "He's been resting when he gets tired."

B) "He was coughing and had a slight fever yesterday and today." Ans: B Feedback: Myasthenic crisis results from stress, exposure to extreme temperatures, and infections. Thus, the parents' statement about a cough and fever suggest an infection. An overdose of anticholinergic medication would lead to a cholinergic crisis. Resting when the child gets tired and lack of stress are appropriate and would not precipitate a myasthenic crisis. Page and Header: 1866, Myasthenia Gravis

10. After teaching the parents of a newborn with periventricular hemorrhage about the disorder and treatment, which statement by the parents indicates that the teaching was successful? A) "We'll make sure to cover both of his eyes to protect them." B) "Our newborn could develop a learning disability later on." C) "Once the bleeding ceases, there won't be any more worries." D) "We need to get family members to donate blood for transfusion."

B) "Our newborn could develop a learning disability later on." Ans: B Feedback: Periventricular-intraventricular hemorrhage has long-term sequelae such as seizures, hydrocephalus, periventricular leukomalacia, cerebral palsy, learning disabilities, vision or hearing deficits, and mental retardation. Covering the eyes is more appropriate for the newborn receiving phototherapy. The bleeding in the brain can lead to serious long-term effects. Blood transfusions are not used to treat periventricular hemorrhage. Page and Header: 918, Nursing Management

23. A child is brought to the emergency department after sustaining a concussion. The child is to be discharged home with his parents. Which of the following would the nurse include in the child's discharge instructions? A) "Expect his headache to get worse initially and then disappear." B) "Wake him every 2 hours to check his movement and responses." C) "Call your medical provider if he vomits more than five times." D) "Any watery fluid draining from his ears is normal."

B) "Wake him every 2 hours to check his movement and responses." Ans: B Feedback: The nurse should instruct the parents to wake the child every 2 hours to ensure that he moves normally and wakes enough to recognize and respond appropriately to them. The parents should be instructed to call the physician or nurse practitioner or bring the child back to the emergency department if he experiences a constant headache that gets worse, vomits more than two times, or has oozing of blood or watery fluid from his ears or nose. Page and Header: 1416, Teaching Guidelines 38.2

11. A woman gives birth to a newborn at 36 weeks' gestation. She tells the nurse, "I'm so glad that my baby isn't premature." Which response by the nurse would be most appropriate? A) "You are lucky to have given birth to a term newborn." B) "We still need to monitor him closely for problems." C) "How do you feel about delivering your baby at 36 weeks?" D) "Your baby is premature and needs monitoring in the NICU."

B) "We still need to monitor him closely for problems." Ans: B Feedback: A baby born at 36 weeks' gestation is considered a late preterm newborn. These newborns face similar challenges as those of preterm newborns and require similar care. Telling the mother that close monitoring is necessary can prevent any misconceptions that she might have and prepare her for what might arise. The baby is not considered a term newborn, nor is the baby considered premature. The decision for care in the NICU would depend on the newborn's status. Asking the woman how she feels about the delivery demonstrates caring but does not address the woman's lack of understanding about her newborn. Page and Header: 896, Late Preterm Newborn

29. A nurse is assisting in the resuscitation of a newborn. The nurse would expect to stop resuscitation efforts when the newborn has no heartbeat and respiratory effort after which time frame? A) 5 minutes B) 10 minutes C) 15 minutes D) 20 minutes

B) 10 minutes Ans: B Feedback: According to the American Heart Association and American Academy of Pediatrics Guidelines for Neonatal Resuscitation, resuscitation efforts may be stopped if the newborn exhibits no heartbeat and no respiratory effort after 10 minutes of continuous and adequate resuscitation. Page and Header: 909, Nursing Management

28. When developing the plan of care for a newborn with an acquired condition, which of the following would the nurse include to promote participation by the parents? A) Use verbal instructions primarily for explanations B) Assist with decision making process C) Provide personal views about their decisions D) Encourage them to refrain from showing emotions

B) Assist with decision making process Ans: B Feedback: To promote parental participation, the nurse should assist them with making decisions about treatment, and support their decisions for the newborn's care. Imposing personal views about their decisions is inappropriate and undermines the nurse-client relationship. In addition, the nurse would assess their ability to cope with the diagnosis, encourage them to verbalize their feelings about the newborn's condition and treatment and educate them about the newborn's condition using written information and pictures to enhance understanding. Page and Header: 909, Nursing Management

8. The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. Which of the following would the nurse use when documenting these observations? A) Spastic B) Athetoid C) Ataxic D) Mixed

B) Athetoid Ans: B Feedback: Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait. Page and Header: 713, Pathophysiology, Table 44.3

11. A newborn has an Apgar score of 6 at 5 minutes. Which of the following is the priority? A) Initiating IV fluid therapy B) Beginning resuscitative measures C) Promoting kangaroo care D) Obtaining a blood culture

B) Beginning resuscitative measures Ans: B Feedback: An Apgar score below 7 at 1 or 5 minutes indicates the need for resuscitation. Intravenous fluid therapy and blood cultures may be done once resuscitation is started. Kangaroo care would be appropriate once the newborn is stable. Page and Header: 624, Nursing Assessment

18. The nurse is assessing the newborn of a mother who had gestational diabetes. Which of the following would the nurse expect to find? (Select all that apply.) A) Pale skin color B) Buffalo hump C) Distended upper abdomen D) Excessive subcutaneous fat E) Long slender neck

B) Buffalo hump C) Distended upper abdomen D) Excessive subcutaneous fat Ans: B, C, D Feedback: Infants of diabetic mothers exhibit full rosy cheeks with a ruddy skin color, short neck, buffalo hump over the nape of the neck, massive shoulders, distended upper abdomen, and excessive subcutaneous fat tissue. Page and Header: 922, Nursing Assessment

3. Which of the following would the nurse include in the plan of care for a newborn receiving phototherapy? A) Keeping the newborn in the supine position B) Covering the newborn's eyes while under the bililights C) Ensuring that the newborn is covered or clothed D) Reducing the amount of fluid intake to 8 ounces daily

B) Covering the newborn's eyes while under the bililights Ans: B Feedback: During phototherapy, the newborn's eyes are covered to protect them from the lights. The newborn is turned every 2 hours to expose all areas of the body to the lights and is kept undressed, except for the diaper area, to provide maximum body exposure to the lights. Fluid intake is increased to allow for added fluid, protein, and calories. Page and Header: 938, Phototherapy

14. Which of the following would the nurse include in the preoperative plan of care for an infant with myelomeningocele? A) Positioning supine with a pillow under the buttocks B) Covering the sac with saline-soaked nonadhesive gauze C) Wrapping the infant snugly in a blanket D) Applying a diaper to prevent fecal soiling of the sac

B) Covering the sac with saline-soaked nonadhesive gauze Ans: B Feedback: For the infant with a myelomeningocele, saline-soaked nonadhesive gauze or antibiotic-soaked gauze is used to keep the sac moist. The infant is positioned prone, with a folded towel under the abdomen, so that the urine and feces flow away from the sac. A warmer or isolette is used to keep the infant warm. Blankets are avoided because they could place excess pressure on the sac. Diapering may be contraindicated to avoid placing pressure on the sac. Page and Header: 1693 Preventing Infection

13. Which of the following, if noted in the maternal history, would the nurse identify as possibly contributing to the birth of an LGA newborn? A) Drug abuse B) Diabetes C) Preeclampsia D) Infection

B) Diabetes Ans: B Feedback: Maternal factors that increase the chance of having an LGA newborn include maternal diabetes mellitus or glucose intolerance, multiparity, prior history of a macrosomic infant, postdated gestation, maternal obesity, male fetus, and genetics. Drug abuse is associated with SGA newborns and preterm newborns. A maternal history of preeclampsia and infection would be associated with preterm birth. Page and Header: 880, Nursing Assessment

6. The nurse prepares to assess a newborn who is considered to be large for gestational age (LGA). Which of the following would the nurse correlate with this gestational age variation? A) Strong, brisk motor skills B) Difficulty in arousing to a quiet alert state C) Birth weight of 7 lb 14 oz D) Wasted appearance of extremities

B) Difficulty in arousing to a quiet alert state Ans: B Feedback: LGA newborns typically are more difficult to arouse to a quiet alert state. They have poor motor skills, have a large body that appears plump and full-sized, and usually weigh more than 8 lb 13 oz at term. Page and Header: 880, Nursing Assessment

16. The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve? A) Optic B) Facial C) Acoustic D) Trigeminal

B) Facial Ans: B Feedback: The most common cranial nerve injury occurring during birth trauma involves facial nerve palsy. The optic, acoustic, and trigeminal nerves are not typically injured during birth trauma. Page and Header: 925, Birth Trauma

15. Which of the following would not be considered a risk factor for bronchopulmonary dysplasia (chronic lung disease)? A) Preterm birth (less than 32 weeks) B) Female gender C) White race D) Sepsis

B) Female gender Ans: B Feedback: Male gender is more commonly associated with bronchopulmonary dysplasia. Preterm birth of less than 32 weeks' gestation, sepsis, white race, excessive fluid intake during the first few days of life, severe RDS with mechanical ventilation for more than 1 week, and patent ductus arteriosus are all risk factors associated with chronic lung disease in the newborn. Page and Header: 911 & 1508, Bronchopulmonary Dysplasia and Chronic Lung Disease

21. A group of students are reviewing information about neuromuscular disorders. The students demonstrate understanding of the information when they identify which of the following as examples of autoimmune neuromuscular disorders? Select all answers that apply. A) Cerebral palsy B) Guillain-Barré syndrome C) Myasthenia gravis D) Spinal muscular atrophy E) Dermatomyositis

B) Guillain-Barré syndrome C) Myasthenia gravis E) Dermatomyositis Ans: B, C, E Feedback: Autoimmune neuromuscular disorders include Guillain-Barré syndrome, myasthenia gravis, and dermatomyositis. Cerebral palsy is associated with brain anoxia. Spinal muscle atrophy is a genetic motor neuron disease. Page and Header: 1861-1867, Acquired Neuromuscular Disorders

2. The nurse knows that children have larger heads in relation to the body and a higher center of gravity. When developing a teaching plan for parents, the nurse includes information about an increased risk for which of the following problems? A) Febrile seizures B) Head trauma C) Caput succedaneum D) Posterior plagiocephaly

B) Head trauma Ans: B Feedback: The larger head size in relation to the body, coupled with a higher center of gravity, causes children to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls. Febrile seizures are not related to anatomy or physiology. Caput succedaneum is an edematous area on the scalp caused by pressure of the uterus or vagina during head-first delivery. Posterior plagiocephaly is caused by early closure of the lamboid suture. Page and Header: 1413, Head Trauma

17. The nurse is reviewing the medical record of a newborn born 2 hours ago. The nurse notes that the newborn was delivered at 35 weeks' gestation. The nurse would classify this newborn as which of the following? A) Preterm B) Late preterm C) Full term D) Postterm

B) Late preterm Ans: B Feedback: A late preterm infant is one born between 34 to 36 6/7 weeks of gestation. A preterm infant is one born before 37 completed weeks' gestation. A full-term infant is one born between 38 to 41 weeks' gestation. A postterm newborn is one born at 42 weeks' gestation or later. Page and Header: 881, Gestational Age Variations

15. When describing newborns with birth-weight variations to a group of nursing students, the instructor identifies which variation if the newborn weighs 5.2 lb at any gestational age? A) Small for gestational age B) Low birth weight C) Very low birth weight D) Extremely low birth weight

B) Low birth weight Ans: B Feedback: A low-birth-weight newborn weighs less than 5.5 lb (2,500 g) but more than 3 lb 5 oz. A very-low-birth-weight newborn would weigh less than 3 lb 5 oz but more than 2 lb 3 oz (1,000 g). An extremely-low-birth-weight newborn weighs less than 2 lb 3 oz (1,000g). A small-for-gestational-age newborn typically weighs less than 5 lb 8 oz (2,500 g) at term. Page and Header: 875, Birthweight Variations

6. A nurse is caring for a 14-year-old girl following myelography. Which of the following would be the priority nursing action? A) Monitoring for a decrease in spasticity B) Observing for signs of meningeal irritation C) Assessing motor function D) Observing for mental confusion or hallucinations

B) Observing for signs of meningeal irritation Ans: B Feedback: Following myelography, the nurse should carefully observe for signs of meningeal irritation because of what is involved in this procedure. Monitoring for a decrease in muscle spasticity, assessing motor function, and observing for mental confusion or hallucinations is appropriate following an intrathecal test dose of baclofen. Page and Header: 1682, Laboratory and Diagnostic Testing, Common Laboratory and Diagnostic Tests 44.1

12. The nurse assesses a child's level of consciousness, noting that the child falls asleep unless he is stimulated. The nurse documents this finding as: A) Confusion B) Obtunded C) Stupor D) Coma

B) Obtunded Ans: B Feedback: Obtunded is a state in which the child has limited responses to the environment and falls asleep unless stimulation is provided. Confusion involves disorientation; the child may be alert but responds inappropriately to questions. Stupor exists when the child responds only to vigorous stimulation. Coma is a state in which the child cannot be aroused even with painful stimuli. Page and Header: 1385, Level of Consciousness (LOC)

6. The nurse prepares to administer a gavage feeding for a newborn with transient tachypnea based on the understanding that this type of feeding is necessary for which reason? A) Lactase enzymatic activity is not adequate. B) Oxygen demands need to be reduced. C) Renal solute lead must be considered. D) Hyperbilirubinemia is likely to develop.

B) Oxygen demands need to be reduced. Ans: B Feedback: For the newborn with transient tachypnea, the newborn's respiratory rate is high, increasing his oxygen demand. Thus, measures are initiated to reduce this demand. Gavage feedings are one way to do so. With transient tachypnea, enzyme activity and kidney function are not affected. This condition typically resolves within 72 hours. The risk for hyperbilirubinemia is not increased. Page and Header: 911, Nursing Management

7. Which of the following would the nurse include when teaching a new mother about the difference between pathologic and physiologic jaundice? A) Physiologic jaundice results in kernicterus. B) Pathologic jaundice appears within 24 hours after birth. C) Both are treated with exchange transfusions of maternal O- blood. D) Physiologic jaundice requires transfer to the NICU.

B) Pathologic jaundice appears within 24 hours after birth. Ans: B Feedback: Pathologic jaundice appears within 24 hours after birth, whereas physiologic jaundice commonly appears around the third to fourth days of life. Kernicterus is more commonly associated with pathologic jaundice. An exchange transfusion is used only if the total serum bilirubin level remains elevated after intensive phototherapy. With this procedure, the newborn's blood is removed and replaced with nonhemolyzed red blood cells from a donor. Physiologic jaundice often is treated at home. Page and Header: 936, Pathologic Jaundice}

30. A newborn is diagnosed with meconium aspiration syndrome. When assessing this newborn, which of the following would the nurse expect to find? (Select all that apply.) A) Pigeon chest B) Prolonged tachypnea C) Intercostal retractions D) High blood pH level E) Coarse crackles on auscultation

B) Prolonged tachypnea C) Intercostal retractions E) Coarse crackles on auscultation Ans: B, C, E Feedback: Assessment findings associated with meconium aspiration syndrome include barrel-shaped chest with an increased anterior-posterior (AP) chest diameter (similar to that found in a client with chronic obstructive pulmonary disease), prolonged tachypnea, progression from mild to severe respiratory distress, intercostal retractions, end-expiratory grunting, and cyanosis. Coarse crackles and rhonchi are noted on lung auscultation. Page and Header: 915, Nursing Assessment

12. Which of the following would be most appropriate for the nurse to do when assisting parents who have experienced the loss of their preterm newborn? A) Avoid using the terms "death" or "dying." B) Provide opportunities for them to hold the newborn. C) Refrain from initiating conversations with the parents. D) Quickly refocus the parents to a more pleasant topic.

B) Provide opportunities for them to hold the newborn. Ans: B Feedback: When dealing with grieving parents, nurses should provide them with opportunities to hold the newborn if they desire. In addition, the nurse should provide the parents with as many memories as possible, encouraging them to see, touch, dress, and take pictures of the newborn. These interventions help to validate the parents' sense of loss, relive the experience, and attach significance to the meaning of loss. The nurse should use appropriate terminology, such as "dying," "died," and "death," to help the parents accept the reality of the death. Nurses need to demonstrate empathy and to respect the parents' feelings, responding to them in helpful and supportive ways. Active listening and allowing the parents to vent their frustrations and anger help validate the parents' feelings and facilitate the grieving process. Page and Header: 898, Dealing with Perinatal Loss, Table 23.2

16. A group of nursing students are reviewing the different types of congenital heart disease in infants. The students demonstrate a need for additional review when they identify which of the following as an example of increased pulmonary blood flow (left-to-right shunting)? A) Atrial septal defect B) Tetralogy of Fallot C) Ventricular septal defect D) Patent ductus arteriosus

B) Tetralogy of Fallot Ans: B Feedback: Tetralogy of Fallot is a congenital heart condition that results from decreased, not increased, pulmonary blood flow. Atrial septal defect, ventricular septal defect, and patent ductus arteriosus are heart conditions that involve increased blood flow from higher pressure (left side of heart) to lower pressure (right side of heart), resulting in left-to-right shunting. Page and Header: 1538 (CH.41), Congenital Heart Disease

10. The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful? A) Myelinization is completed by 4 years of age. B) The process occurs in a head-to-toe fashion. C) The speed of nerve impulses slows as myelinization occurs. D) Nerve impulses become less specific in focus with myelinization.

B) The process occurs in a head-to-toe fashion. Ans: B Feedback: Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2 years of age. As myelinization proceeds, nerve impulses become faster and more accurate. Page and Header: 1673, Myelinization

13. During a well-child visit, the nurse assesses an infant's ability to suck on a pacifier. The nurse is assessing which cranial nerve? A) Olfactory B) Trigeminal C) Facial D) Accessory

B) Trigeminal Ans: B Feedback: To test the trigeminal nerve, the nurse would note the strength of the infant's suck on a pacifier, thumb, or bottle. The olfactory nerve is not assessed in infants and young children. The facial nerve is assessed by noting the symmetry of facial expressions. For the infant, this would be assessed during spontaneous crying or smiling. The accessory nerve is assessed when the infant is in the sitting position and symmetry of the head position is noted. Page and Header: 1386, Cranial Nerve Function, Table 38.1

4. The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion? A) Deep-breathing exercises B) Upright positioning C) Coughing D) Chest percussion

B) Upright positioning Ans: B Feedback: The nurse should emphasize that the child's position should be arranged to promote maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest percussion helps loosen secretions in lungs. Page and Header: 1709, Maintaining Cardiopulmonary Function

8. When planning the care of a newborn addicted to cocaine who is experiencing withdrawal, which of the following would be least appropriate to include? A) Wrapping the newborn snugly in a blanket B) Waking the newborn every hour C) Checking the newborn's fontanels D) Offering a pacifier

B) Waking the newborn every hour Ans: B Feedback: Stimuli need to be decreased. Waking the newborn every hour would most likely be too stimulating. Measures such as swaddling the newborn tightly and offering a pacifier help to decrease irritable behaviors. A pacifier also helps to satisfy the newborn's need for nonnutritive sucking. Checking the fontanels provides evidence of hydration. Page and Header: 934, Promoting Comfort

22. A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which of the following would the instructor include? Select all answers that apply. A) Onset before 6 months of age B) Weakness most severe in shoulders and hips C) Difficulty with swallowing D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance

B) Weakness most severe in shoulders and hips D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance Ans: B, D, E Feedback: Any type of spinal muscular atrophy is a genetic motor neuron disease due to autosomal recessive inheritance. Type 2 SMA usually occurs between 6 and 18 months of age, with weakness that is most severe in the shoulders, hips, thighs, and upper back. It is slower in progression than type 1. Survival into adulthood is common if respiratory status is maintained appropriately. Type 1 SMA occurs before birth to 6 months of age and the child usually has difficulty swallowing, sucking, and breathing. Page and Header: 1710, Spinal Muscular Atrophy, Table 44.2

Chapter 44 Nursing Care of the Child With an Alteration in Mobility / Neuromuscular or Musculoskeletal Disorder Maternity and Pediatric Nursing 1. The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which of the following responses from his mother indicates a need for further teaching? A) "He needs to get a medical alert identification." B) "I will need to discuss this with his caregivers." C) "A product's label indicates whether it is latex-free." D) "He must avoid all contact with latex."

C) "A product's label indicates whether it is latex-free." Ans: C Feedback: The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain latex, but this is not the case with consumer products. The mother must be familiar with products that contain latex. The Spina Bifida Association of America maintains an updated list of latex-containing products. Getting a medical alert identification, talking with his caregivers, and avoiding all contact with latex are correct. Page and Header: 1695, Preventing Latex Allergic Reaction

20. A nurse is providing teaching to the parents of a child who has had a shunt inserted as treatment for hydrocephalus. The parents demonstrate understanding of the teaching when they state which of the following? A) "Having the shunt put in decreases his risk for developmental problems." B) "If he doesn't get an infection in the first week, the risk is greatly reduced." C) "He will need more surgeries to replace the shunt as he grows." D) "The shunt will help to prevent any further complications from his disease."

C) "He will need more surgeries to replace the shunt as he grows." Ans: C Feedback: Parents need to know that hydrocephalus is a chronic illness that requires lifelong follow-up and regular evaluations, including future surgeries as the child grows. The risk for infection is ever present, but is most common 1 to 2 months after shunt placement. The child with a shunt and hydrocephalus is at risk for potential growth and developmental disabilities as well as complications such as infection and malfunction of the shunt. Page and Header: 1405, Supporting and Educating the Child and Family

5. A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate? A) "Would you like me to bring you a blanket and pillow?" B) "You are doing such a wonderful job with your son." C) "He's in good hands; consider going home to get some sleep." D) "Are you planning to spend the night or to go home?"

C) "He's in good hands; consider going home to get some sleep." Ans: C Feedback: Providing daily, intense care can be quite demanding and tiring. When a child with cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and primary caregivers. The nurse should remind the mother that her son is in good hands and urge her to go home. Asking her whether she is planning to stay might make the mother feel obligated to stay. Asking if she wants a blanket or pillow does not encourage the mother to leave the hospital. Telling the mother she is doing a good job is nice, but does not encourage her to take a break. Page and Header: 1716, Providing Support and Education

19. The nurse is assessing a newborn who is large for gestational age. The newborn was born breech. The nurse suspects that the newborn may have experienced trauma to the upper brachial plexus based on which assessment findings? A) Absent grasp reflex B) Hand weakness C) Absent Moro reflex D) Facial asymmetry

C) Absent Moro reflex Ans: C Feedback: An injury to the upper brachial plexus, or Erb's palsy, is manifested by adduction, pronation, and internal rotation of the affected extremity, absent shoulder movement, absent Moro reflex and positive grasp reflex. An absent grasp reflex and hand weakness is noted with a lower brachial plexus injury. Facial asymmetry is associated with a cranial nerve injury. Page and Header: 925, Pathophysiology, Table 24.3

8. A group of pregnant women are discussing high-risk newborn conditions as part of a prenatal class. When describing the complications that can occur in these newborns to the group, which would the nurse include as being at lowest risk? A) Small-for-gestational-age (SGA) newborns B) Large-for-gestational-age (LGA) newborns C) Appropriate-for-gestational-age (AGA) newborns D) Low-birth-weight newborns

C) Appropriate-for-gestational-age (AGA) newborns Ans: C Feedback: Appropriate-for-gestational-age (AGA) newborns are at the lowest risk for any problems. AGA characterizes approximately 80% of newborns and describes a newborn with a normal length, weight, head circumference, and body mass index. The other categories all have an increased risk of complications. Page and Header: 875, Birthweight Variations

24. Assessment of newborn reveals a large protruding tongue, slow reflexes, distended abdomen, poor feeding, hoarse cry, goiter and dry skin. Which of the following would the nurse suspect? A) Phenylketonuria B) Galactosemia C) Congenital hypothyroidism D) Maple syrup urine disease

C) Congenital hypothyroidism Ans: C Feedback: The manifestations listed correlate with congenital hypothyroidism. With phenylketonuria, the infant appears normal at birth but by 6 months of age, signs of slow mental development are evident. Vomiting, poor feeding, failure to thrive, overactivity and musty-smelling urine are additional signs. With maple syrup urine disease, signs and symptoms include lethargy, poor feeding, vomiting, weight loss, seizures, shrill cry, shallow respirations, loss of reflexes, and a sweet maple syrup odor to the urine. With galactosemia, manifestations include vomiting, hypoglycemia, hyperbilirubinemia, poor weight gain, cataracts, and frequent infections. Page and Header: 1896 (CH.48), Inborn Errors of Metabolism

5. The nurse frequently assesses the respiratory status of a preterm newborn based on the understanding that the newborn is at increased risk for respiratory distress syndrome because of which of the following? A) Inability to clear fluids B) Immature respiratory control center C) Deficiency of surfactant D) Smaller respiratory passages

C) Deficiency of surfactant Ans: C Feedback: A preterm newborn is at increased risk for respiratory distress syndrome (RDS) most commonly because of a surfactant deficiency. Surfactant helps to keep the alveoli open and maintain lung expansion. With a deficiency, the alveoli collapse, predisposing the newborn to RDS. An inability to clear fluids can lead to transient tachypnea. Immature respiratory control centers lead to an increased risk for apnea. Smaller respiratory passages lead to an increased risk for obstruction. Page and Header: 888, Administering Oxygen

13. A newborn is suspected of developing persistent pulmonary hypertension. The nurse would expect to prepare the newborn for which of the following to confirm the suspicion? A) Chest x-ray B) Blood cultures C) Echocardiogram D) Stool for occult blood

C) Echocardiogram Ans: C Feedback: An echocardiogram is used to reveal right-to-left shunting of blood to confirm the diagnosis of persistent pulmonary hypertension. Chest x-ray would be most likely used to aid in the diagnosis of RDS or TTN. Blood cultures would be helpful in evaluating for neonatal sepsis. Stool for occult blood may be done to evaluate for NEC. Page and Header: 917, Nursing Assessment

3. The parents of a preterm newborn being cared for in the neonatal intensive care unit (NICU) are coming to visit for the first time. The newborn is receiving mechanical ventilation and intravenous fluids and medications and is being monitored electronically by various devices. Which action by the nurse would be most appropriate? A) Suggest that the parents stay for just a few minutes to reduce their anxiety. B) Reassure them that their newborn is progressing well. C) Encourage the parents to touch their preterm newborn. D) Discuss the care they will be giving the newborn upon discharge.

C) Encourage the parents to touch their preterm newborn. Ans: C Feedback: The NICU environment can be overwhelming. Therefore, the nurse should address their reactions and explain all the equipment being used. On entering the NICU, the nurse should encourage the parents to touch, interact, and hold their newborn. Doing so helps to acquaint the parents with their newborn, promotes self-confidence, and fosters parent-newborn attachment. The parents should be allowed to stay for as long as they feel comfortable. Reassurance, although helpful, may be false reassurance at this time. Discussing discharge care can be done later once the newborn's status improves and plans for discharge are initiated. Page and Header: 895, Promoting Parental Coping

9. A newborn is suspected of having fetal alcohol syndrome. Which of the following would the nurse expect to assess? A) Bradypnea B) Hydrocephaly C) Flattened maxilla D) Hypoactivity

C) Flattened maxilla Ans: C Feedback: A newborn with fetal alcohol syndrome exhibits characteristic facial features such as microcephaly (not hydrocephaly), small palpebral fissures, and abnormally small eyes, flattened or absent maxilla, epicanthal folds, thin upper lip, and missing vertical groove in the median portion of the upper lip. Bradypnea is not typically associated with fetal alcohol syndrome. Fine and gross motor development is delayed, and the newborn shows poor hand-eye coordination but not hypoactivity. Page and Header: 931, Fetal Alcohol Spectrum Disorders, Box 24.2

5. As a result of seizure activity, a computed tomography (CT) scan was performed and showed that an 18-month-old child has intracranial arteriovenous malformation. When developing the child's plan of care, the nurse would expect to implement actions to prevent which of the following? A) Drug interactions B) Developmental disabilities C) Hemorrhagic stroke D) Respiratory paralysis

C) Hemorrhagic stroke Ans: C Feedback: Intracranial hemorrhage or hemorrhagic stroke is a risk for children with intracranial arteriovenous malformation. Drug interactions are a risk for children who are treated with combinations of anticonvulsants for epilepsy. Children with hydrocephalus are at an increased risk for developmental disabilities. Respiratory paralysis is a risk of botulism that typically affects infants younger than 6 months of age. Page and Header: 1389 & 1421, Nursing Management

2. Which of the following would the nurse expect to assess in a newborn who develops sepsis? A) Increased urinary output B) Interest in feeding C) Hypothermia D) Wakefulness

C) Hypothermia Ans: C Feedback: Manifestations of sepsis are typically nonspecific and may include hypothermia (temperature instability), oliguria or anuria, lack of interest in feeding, and lethargy. Page and Header: 1348 (CH.37), Nursing Assessment

12. A nurse is preparing a program for a group of parents about injury prevention. Which of the following would the nurse include as an important contributing factor for cervical spine injury in a child? A) Exposure to teratogens while in utero B) Immaturity of the central nervous system C) Increased mobility of the spine D) Incomplete myelinization

C) Increased mobility of the spine Ans: C Feedback: Compared to the adult, a child's spine is very mobile, especially in the cervical spine region, resulting in a higher risk for cervical spine injury. Exposure to teratogens in utero may lead to altered growth and development of the brain or spinal cord. Immaturity of the central nervous system places the infant at risk for insults that may result in delayed motor skill attainment or cerebral palsy. Incomplete myelinization reflects the lack of motor control. Page and Header: 1673, Brain and Spinal Cord Development

Chapter 38 Nursing Care of the Child With an Alteration in Intracranial Regulation / Neurologic Disorder Maternity and Pediatric Nursing 1. When providing care to a newborn infant who was born at 29 weeks' gestation, the nurse integrates knowledge of potential complications, being alert for signs and symptoms of which of the following? A) Neonatal conjunctivitis B) Facial deformities C) Intracranial hemorrhage D) Incomplete myelinization

C) Intracranial hemorrhage Ans: C Feedback: Premature infants have more fragile capillaries in the periventricular area than term infants, which puts them at greater risk for intracranial hemorrhage. Neonatal conjunctivitis can occur in any newborn during birth and is caused by viruses, bacteria, or chemicals. Facial deformities are typical of babies of alcoholic mothers. Incomplete myelinization is present in all newborns. Page and Header: 1381, Brain and Spinal Cord Development

17. A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route? A) Oral B) Subcutaneous injection C) Intramuscular injection D) Intravenous infusion

C) Intramuscular injection Ans: C Feedback: Botulin toxin is administered by injection into the muscle. It may cause dry mouth. It is not administered orally, by subcutaneous injection, or by intravenous infusion. Page and Header: 1677, Common Medical Treatments, Drug Guide 44.1

26. A nurse is teaching the mother of a newborn diagnosed with galactosemia about dietary restrictions. The nurse determines that the mother has understood the teaching when she identifies which of the following as needing to be restricted? A) Phenylalanine B) Protein C) Lactose D) Iodine

C) Lactose Ans: C Feedback: Lifelong restriction of lactose is required for galactosemia. Phenylalanine is restricted for those with phenylketonuria. Low protein is needed with maple syrup urine disease. Iodine would not be restricted for any inborn error of metabolism Page and Header: 657 & 1948, Inborn Errors of Metabolism

19. Hydrocephalus is suspected in a 4-month-old infant. Which of the following would the nurse expect to assess? A) Sunken fontanels B) Diminished reflexes C) Lower extremity spasticity D) Skull symmetry

C) Lower extremity spasticity Ans: C Feedback: Hydrocephalus is manifested by spasticity of lower extremities, bulging fontanels, brisk reflexes, and skull asymmetry. Page and Header: 1404, Inspection and Observation

25. A group of students are reviewing information about the effects of substances on the newborn. The students demonstrate understanding of the information when they identify which drug as not being associated with teratogenic effects on the fetus? A) Alcohol B) Nicotine C) Marijuana D) Cocaine

C) Marijuana Ans: C Feedback: Marijuana has not been shown to have teratogenic effects on the fetus. Alcohol, nicotine and cocaine do affect the fetus. Page and Header: 928, Newborns of Substance-Abusing Mothers

24. A group of nursing students are reviewing the literature in preparation for a class presentation on newborn pain prevention and management. Which of the following would the students be most likely to find about this topic? A) Newborn pain is frequently recognized and treated B) Newborns rarely experience pain with procedures C) Pain is frequently mistaken for irritability or agitation D) Newborns may be less sensitive to pain than adult.

C) Pain is frequently mistaken for irritability or agitation Ans: C Feedback: Assessment of pain in the newborn remains a contentious and vexing problem. According to an international consortium, principles of newborn pain prevention and management include the following: newborn pain frequently goes unrecognized and undertreated; newborns experience pain and analgesics should be given; a procedure considered painful for an adults should also be considered painful for a newborn; newborns may be more sensitive to pain than adults; and pain behavior is frequently mistaken for irritability and agitation. Page and Header: 892, Managing Pain, Box 23.4

9. The nurse is caring for an 8-year-old boy who has chronic epilepsy. Which of the following would be most important to address when teaching the child and parents about living with this condition? A) Multiple corrective surgeries to slowly remove diseased parts of his brain B) Physical, occupational, and speech therapy to maximize his potential C) Support for maintaining self-esteem because of his altered lifestyle D) Hyperventilation therapy to counteract the periods of decreased oxygenation

C) Support for maintaining self-esteem because of his altered lifestyle Ans: C Feedback: The effects of living with a seizure disorder can be devastating, and it is essential for the child to receive support to maintain self-esteem. While corrective surgery is possible, it would only be performed once. Physical, occupational, speech, and hyperventilation therapy are not indicated for treatment of epilepsy. Page and Header: 1398, Providing Family Support and Education

23. A nursing student is preparing a presentation for the class on clubfoot. The student determines that the presentation was successful when the class states which of the following? A) Clubfoot is a common genetic disorder. B) The condition affects girls more often than boys. C) The exact cause of clubfoot is not known. D) The intrinsic form can be manually reduced.

C) The exact cause of clubfoot is not known. Ans: C Feedback: Clubfoot is a complex, multifactorial deformity with genetic and intrauterine factors. Heredity and race seem to factor into the incidence, but the means of transmission and the etiology are unknown. Most newborns with clubfoot have no identifiable genetic, syndromal, or extrinsic cause. Clubfoot affects boys twice as often as girls. With the intrinsic type, manual reduction is not possible. Page and Header: 1698 (CH.44), Congenital Clubfoot

2. When assessing a postterm newborn, which of the following would the nurse correlate with this gestational age variation? A) Moist, supple, plum skin appearance B) Abundant lanugo and vernix C) Thin umbilical cord D) Absence of sole creases

C) Thin umbilical cord Ans: C Feedback: A postterm newborn typically exhibits a thin umbilical cord; dry, cracked, wrinkled skin; limited vernix and lanugo; and creases covering the entire soles of the feet. Page and Header: 876, Nursing Assessment

26. A nurse is assisting the anxious parents of a preterm newborn to cope with the situation. Which statement by the nurse would be least appropriate? A) "I'll be here to help you all along the way." B) "What has helped you to deal with stressful situations in the past?" C) "Let me tell you about what you will see when you visit your baby." D) "Forget about what's happened in the past and focus on the now."

D) "Forget about what's happened in the past and focus on the now." Ans: D Feedback: Instead of telling the parents to forget about what's happened, the nurse should review with them the events that have occurred since birth to help them understand and clarify any misconceptions they might have. Other helpful interventions would include telling the parents that the nurse will be with them because this provides them with a physical presence and support; asking about previous coping strategies that worked so that they can use them now; and explaining what is happening and all the equipment being used so they can understand the situation. Page and Header: 894-895, Promoting Parental Coping

14. Which of the following would alert the nurse to suspect that a newborn has developed NEC? A) Irritability B) Sunken abdomen C) Clay-colored stools D) Bilious vomiting

D) Bilious vomiting Ans: D Feedback: The newborn with NEC may exhibit bilious vomiting with lethargy, abdominal distention and tenderness, and bloody stools. Page and Header: 918, Health History and Physical Examination

20. A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which of the following would the nurse include when teaching the parents about caring for their child? A) Waiting 48 hours before allowing the child to take a tub bath B) Not allowing the child to sleep on his side for about 4 weeks C) Calling the physician if the child's temperature is over 100.5°F D) Discouraging the child from stretching or bending forward for 4 weeks

D) Discouraging the child from stretching or bending forward for 4 weeks Ans: D Feedback: After insertion of a baclofen pump, the parents should discourage any twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks. The child would avoid tub baths for about 2 weeks and avoid sleeping on his stomach for 4 weeks. The parents should notify the physician or nurse practitioner if the child's temperature is greater than 101.5°F. Page and Header: 1716, Promoting Mobility, Teaching Guidelines 44.2

25. After teaching a class of nursing students about muscular dystrophy, the instructor determines that the teaching was successful when the students identify which type of muscular dystrophy as demonstrating an X-linked recessive pattern of inheritance? A) Limb-girdle B) Myotonic C) Distal D) Duchenne

D) Duchenne Ans: D Feedback: Duchenne muscular dystrophy follows an X-linked recessive inheritance pattern. Limb-girdle muscular dystrophy is believed to be autosomal or X-linked inherited. Myotonic and distal muscular dystrophy follow an autosomal dominant inheritance pattern. Page and Header: 1706, Muscular Dystrophy, Table 44.1

16. A nurse is talking with the parents of a child who has had a febrile seizure. The nurse would integrate an understanding of which of the following into the discussion? A) The child's risk for cognitive problems is greatly increased. B) Structural damage occurs with febrile seizure. C) The child's risk for epilepsy is now increased. D) Febrile seizures are benign in nature.

D) Febrile seizures are benign in nature. Ans: D Feedback: Parents need reassurance that febrile seizures, although frightening, are benign in nature. Children who experience one or more febrile seizures are at no greater risk of developing epilepsy than the general population. No evidence exists that febrile seizures cause structural damage or cognitive declines. Page and Header: 1399, Nursing Management

21. A nurse is preparing a presentation for an expectant parent group about neural tube defects and prevention. Which of the following would the nurse emphasize? A) Smoking cessation B) Aerobic exercise C) Increased calcium intake D) Folic acid supplementation

D) Folic acid supplementation Ans: D Feedback: The cause of neural tube defects is unknown, but there is strong evidence to support the use of folic acid supplementation for prevention. Smoking cessation and aerobic exercise are general health recommendations unrelated to neural tube defects. Increased calcium intake is important for fetal growth and development, but it is not linked to preventing neural tube defects. Page and Header: 1400, Neural Tube Defects

Chapter 23- Nursing Care of the Newborn With Special Needs Maternity and Pediatric Nursing 1. The nurse is teaching a group of students about the differences between a full-term newborn and a preterm newborn. The nurse determines that the teaching is effective when the students state that the preterm newborn has: A) Fewer visible blood vessels through the skin B) More subcutaneous fat in the neck and abdomen C) Well-developed flexor muscles in the extremities D) Greater surface area in proportion to weight

D) Greater surface area in proportion to weight Ans: D Feedback: Preterm newborns have large body surface areas compared to weight, which allows an increased transfer of heat from their bodies to the environment. Preterm newborns often have thin transparent skin with numerous visible veins, minimal subcutaneous fat, and poor muscle tone. Page and Header: 889, Maintaining Thermal Regulation

26. During class, a student states, "I didn't think children could have strokes. I thought this only occurred in older adults." When responding to the student, which of the following would be most important for the instructor to integrate into the response? A) Strokes in children often have an identifiable cause. B) The signs and symptoms in children are different from an adult. C) Research has identified specific treatments for children. D) Ischemic strokes are more common than hemorrhagic strokes.

D) Ischemic strokes are more common than hemorrhagic strokes. Ans: D Feedback: In children, ischemic strokes are more common than hemorrhagic strokes. However, the cause of the stroke in many children remains unidentified. Signs and symptoms are similar to those in adults and will vary based on age; underlying cause, if known; and location of the stroke. Historically, children have been excluded from adult stroke studies and thus, many treatments used have had to be adapted from adult studies. Page and Header: 1420, Cerebral Vascular Disorders (Stroke)

15. Which of the following would the nurse expect to find initially in a child with Guillain-Barré syndrome? A) Symmetric flaccid weakness B) Ataxia C) Sensory disturbances D) Lower extremity pain

D) Lower extremity pain Ans: D Feedback: Although symmetric flaccid weakness or paralysis, ataxia, and sensory disturbances may be assessed, pain, especially in the lower extremities, is commonly the initial presenting finding, preceding motor involvement. Page and Header: 1864, Health History

4. A newborn has been diagnosed with a Group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which of the following? A) Improper handwashing B) Contaminated formula C) Nonsterile catheter insertion D) Mother's birth canal

D) Mother's birth canal Ans: D Feedback: Most often, a newborn develops a Group B streptococcus infection during the birthing process when the newborn comes into contact with an infected birth canal. Improper handwashing, contaminated formula, and nonsterile catheter insertion would most likely lead to a late-onset infection, which typically occurs in the nursery due to horizontal transmission. Page and Header: 942, Pathophysiology, Comparison Chart 24.2

18. A group of nursing students are reviewing information related to seizures that occur in infants and children. The students demonstrate a need for additional review when they identify which type as common in neonates? A) Tonic B) Focal clonic C) Multifocal clonic D) Myoclonic

D) Myoclonic Ans: D Feedback: Five major types of seizures have been recognized in the neonatal period: subtle, tonic, focal clonic, multifocal clonic, and myoclonic. Of these, myoclonic seizures rarely occur during the neonatal period. Subtle seizures affect preterm and full-term neonates. Tonic seizures primarily occur in preterm neonates. Focal clonic and multifocal clonic are more common in full-term neonates. Page and Header: 1399, Nursing Assessment, Table 38.4

15. Which of the following would lead the nurse to suspect that a child is beginning to develop increased intracranial pressure? A) Bradycardia B) Cheyne-Stokes respirations C) Fixed, dilated pupils D) Projectile vomiting

D) Projectile vomiting Ans: D Feedback: Projectile vomiting is an early sign of increased intracranial pressure. Bradycardia, Cheyne-Stokes respirations, and fixed dilated pupils are late signs of increased intracranial pressure. Page and Header: 1388, Increased Intracranial Pressure, Comparison Chart 38.1

7. A 4-year-old boy has a febrile seizure during a well-child visit. Which of the following would be a priority? A) Hyperextending the child's head while placing him on his side B) Using a tongue blade to pry open the child's jaw C) Loosening the child's clothing to ensure a patent airway D) Protecting the child from harm during the seizure

D) Protecting the child from harm during the seizure Ans: D Feedback: During a seizure, the child should not be held down in a specific position. Protecting the child's head and body during the seizure is the priority. Ensuring a patent airway is an important intervention but is not accomplished by loosening the child's clothing or hyperextending his head. The child should be placed on his side and nothing should be inserted into his mouth to forcibly open the jaw. Page and Header: 1398, Relieving Anxiety, Teaching Guidelines 38.1

7. The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury? A) Recommend the bed's side rails be raised throughout the day and night. B) Suggest a caregiver be present continuously to prevent falls from bed. C) Encourage a loose restraint to be used when he is in bed. D) Recommend raising the bed's side rails when a caregiver is not present.

D) Recommend raising the bed's side rails when a caregiver is not present. Ans: D Feedback: The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby." Page and Header: 1705, Nursing Diagnoses, Goals, Interventions, and Evaluations, Nursing Care Plan 44.1

19. The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. Which of the following would the nurse include? A) Applying petroleum jelly to lubricate the catheter B) Cleaning the reusable catheter with peroxide after each use C) Storing the reusable cleaned catheter in a brown paper bag D) Soaking the catheter in a vinegar and water solution to sterilize

D) Soaking the catheter in a vinegar and water solution to sterilize Ans: D Feedback: When teaching parents how to perform clean intermittent catheterization, the nurse would instruct the parents to apply a water-based lubricant to the catheter, clean the reusable catheter with soap and water after each use, store the reusable clean catheter in a zip-top bag or other clean storage container, and soak the catheter in a 1:1 vinegar and water solution for about 30 minutes weekly, rinsing well before the next use or placing the catheter in boiling water for 10 minutes. Page and Header: 1694, Performing Clean Intermittent Catheterization, Teaching Guidelines 44.1

22. The nurse is assessing a preterm newborn's fluid and hydration status. Which of the following would alert the nurse to possible overhydration? A) Decreased urine output B) Tachypnea C) Bulging fontanels D) Elevated temperature

C) Bulging fontanels Ans: C Feedback: Bulging fontanels in a preterm newborn suggest overhydration. Sunken fontanels, decreased urine output, and elevated temperature would suggest dehydration. Page and Header: 890, Promoting Nutrition and Fluid Balance

2. The nurse is caring for an 8-year-old boy with myasthenia gravis and is teaching his parents about the signs of cholinergic crisis. Which of the following responses by the parents indicates a need for further teaching? A) "Low blood pressure is a sign of crisis." B) "He might have difficulty swallowing." C) "He may start to sweat a lot." D) "More saliva in the mouth is a common sign."

B) "He might have difficulty swallowing." Ans: B Feedback: Dysphagia is a sign of myasthenic crisis. Increased salivation, hypotension, and increased sweating are signs and symptoms of cholinergic crisis. Page and Header: 1866 (CH.47), Nursing Management

8. The nurse has developed a teaching plan for the family of a 2-year-old boy who holds his breath when he gets frustrated. Which of the following will be most important to include in this plan? A) Provide cuddle time whenever the child begins to act out. B) Explain the child's behavior to the parents. C) Encourage the parents to interact more with the child. D) Stay close to prevent injury when he gets frustrated.

D) Stay close to prevent injury when he gets frustrated. Ans: D Feedback: Encourage the parents to maintain a safe environment when an episode is occurring, but to avoid giving extra attention to the child after the event since this could encourage repetition of the behavior. It is important for the parents to understand what is happening, but rewarding the child with cuddle time when he is misbehaving provides incorrect reinforcement of behaviors. Encouraging the parents to interact more with the child may be helpful, but the priority is safety for the child. Page and Header: 1423, Nursing Management

4. When performing newborn resuscitation, which action would the nurse do first? A) Intubate with an appropriate-sized endotracheal tube. B) Give chest compressions at a rate of 80 times per minute. C) Administer epinephrine intravenously. D) Suction the mouth and then the nose.

D) Suction the mouth and then the nose. Ans: D Feedback: After placing the newborn's head in a "sniffing" position, the nurse would suction the mouth and then the nose. This is followed by ventilation, circulation (chest compressions), and administration of epinephrine. Page and Header: 888, Resuscitating the Newborn, Box 23.3

14. Which of the following would alert the nurse to suspect that a preterm newborn is in pain? A) Bradycardia B) Oxygen saturation level of 94% C) Decreased muscle tone D) Sudden high-pitched cry

D) Sudden high-pitched cry Ans: D Feedback: The nurse should suspect pain if the newborn exhibits a sudden high-pitched cry, oxygen desaturation, tachycardia, and increased muscle tone. Page and Header: 892, Managing Pain

6. A 16-year-old boy complains to the school nurse of headaches and a stiff neck. Which of the following signs and symptoms would alert the nurse that the child may have bacterial meningitis? A) Fixed and dilated pupils B) Frequent urination C) Sunset eyes D) Sunlight is "too bright"

D) Sunlight is "too bright" Ans: D Feedback: Photophobia, or intolerance of light, is another symptom of bacterial meningitis. Fixed and dilated pupils are a symptom of head trauma and warrant prompt intervention. Frequent urination is a symptom of a type I Arnold-Chiari malformation. Sunset eyes indicate increased intracranial pressure typical of hydrocephalus. Page and Header: 1409, Health History

14. The nurse inspects the eyes of a child and observes that the sclera is showing over the top of the iris. The nurse documents this finding as: A) Decorticate posturing B) Nystagmus C) Doll's eye D) Sunsetting

D) Sunsetting Ans: D Feedback: Sunsetting is when the sclera of the eyes is showing over the top of the iris. Decorticate posturing includes adduction of the arms, flexion at the elbows with the arms held over the chest, and flexion of the wrists with both hands fisted and the lower extremities adducted and extended. Nystagmus is manifested by involuntary rapid rhythmic eye movements. Doll's eye is a maneuver that tests for symmetric eye movement to the opposite side when the head is turned in the other direction. Page and Header: 1386, Cranial Nerve Function