PEDIATRIC EAQs

A school-age child often steals money from home to buy chocolate. Upon being confronted by the parents, the child lies about stealing. The parents are worried that such behavior will steer the child toward criminal activities later in life. What is the best response from the nurse? .

1 "It is a normal behavior, and the child will grow out of it later." Correct 2 "Use admonition and ask the child to return the stolen money." 3 "Catch the child in the act of stealing and ask for an explanation." 4 "Inform all the family members and teachers about this behavior." The nurse should tell the parents that it is not necessary to attach any deep meaning to the child's stealing habits. With admonition and appropriate discipline the child will grow out of it. Simple punishment, like asking the child to return the stolen money, will help the child develop respect for other people's property. Stealing is not a normal behavior, and the nurse needs to instruct the parents that the behavior will be altered only if corrective measures are implemented. Catching the child in the act of stealing is not effective, because the child will refuse to accept responsibility for the act. Informing all the family members or teachers about this behavior will not help in curtailing this habit; rather, it will make the child feel ashamed

6. What should the nurse teach the parent of an infant who is at risk for infections?

1 "You must avoid placing the infant in bright sunlight." Correct 2 "Breast-feeding will provide protection against bacteria." 3 "Use soy-based infant formulas to help prevent infection." Incorrect 4 "The infant will be less susceptible to infections later in life." Breast milk contains immunoglobulin G (IgG) that protects the infant against many bacteria, such as Escherichia coli. The nurse instructs the parent to avoid placing the infant in bright sunlight for a long period of time to prevent burns, but not to prevent infections. Soy-based infant formulas are used only if the infant is allergic to lactose in the breast milk and is not used to prevent the risk for infections. Later, susceptibility would be dependent on multiple factors, including nutrition and exposure to infections.

A father expresses concern that his 2-year-old daughter has become a "finicky eater" and is eating less. How should the nurse respond?

1 "Your daughter has become manipulative." 2 "She's probably experiencing the stress of a typical 2-year-old." 3 "She may have an eating problem that requires a referral to a specialist." Correct 4 "Your daughter's behavior is expected in response to her slower growth." Growth slows during the toddler years, and these children generally do not eat as much as they do during infancy; this is called physiologic anorexia, which is typical of this age group. Toddlers may try to manipulate as they assert their autonomy, but usually not through eating behaviors unless the parents express anxiety and concern over their food intake. Although toddlers have difficulty withstanding frustration and are prone to temper tantrums, these eating behaviors are within the norm for toddlers. Eating disorders usually do not occur in children this young; these behaviors are typical of healthy toddlers. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

At what age does an infant achieve permanent eye color?

1 2 weeks 2 30 months 3 2 months Correct 4 6 months Permanent eye color is usually established between 6 and 12 months of age. Two weeks and 2 months are too early to have developed permanent eye color. A child of age 30 months has long developed permanent eye color. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

The parent of a 10-month-old infant with otitis media tells the nurse in the pediatric clinic that this is the baby's third episode in 3 months. The infant is tugging at the ear but is not acutely ill. What factor should the nurse consider before responding?

1 Analgesics are contraindicated. 2 Oral antibiotics will be prescribed. 3 The labyrinth and cochlea are inflamed. Correct 4 The eustachian tube is short and horizontal. This anatomical difference in young children permits easier migration of microorganisms from the oral cavity into the middle ear, predisposing them to otitis media. Analgesics such as acetaminophen or ibuprofen are recommended to relieve discomfort. Studies have shown that antibiotics are not effective in children younger than 2 years if the child is not severely ill. Antibiotic therapy is necessary when the infant has a fever or is in severe pain. The labyrinth and cochlea are part of the inner ear and are not affected by otitis media.

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag?

1 Auscultating for breath sounds Correct 2 Removing the tube, then reinserting it 3 Administering the tube feeding slowly 4 Observing the infant for circumoral cyanosis The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

According to Erikson, what should the nurse anticipate when assessing an adolescent?

1 Being engaged in tasks Correct 2 Questioning sexual identity 3 Having highly imaginative thoughts Incorrect 4 Wanting to participate in organized activities The nurse would anticipate the adolescent to question sexual identity, according to Erikson. Being engaged in tasks and wanting to participate in organized activities is expected for the school-age child. The nurse would anticipate that a preschool-age child would have highly imaginative thoughts.

A nurse provides clapping, percussion, and postural drainage every 4 hours for a 3-month-old infant with cystic fibrosis. When is the best time for the nurse to schedule chest physiotherapy?

1 During every feeding Correct 2 Two hours after feedings 3 Right after every feeding 4 Right before every feeding Chest physiotherapy is done midway between feedings (about 2 hours before or after a feeding). This will decrease the likelihood of vomiting and increase drainage of respiratory secretions. Performing chest physiotherapy right after a feeding may cause the infant to vomit the feeding. Performing chest physiotherapy right before a feeding will tire the infant and possibly lead to impaired nutritional intake. Performing chest physiotherapy during a feeding is contraindicated; the infant may vomit, and nutritional intake will be impaired.

The neonate has a protruding tongue and a crease that transverses the entire width of each palm. The nurse recognizes that these findings are characteristic of what congenital condition?

1 Hypothyroidism Correct 2 Down syndrome 3 Turner syndrome 4 Fetal alcohol syndrome Dysmorphic features that are characteristic of Down syndrome include a protruding tongue and simian creases across the palms. A protruding tongue but not the transverse palmar creases may also occur with hypothyroidism. Turner syndrome is characterized by a webbed neck and peripheral edema. Children with fetal alcohol syndrome have dysmorphic features, but these are different from the ones that occur with Down syndrome.

The student nurse is classifying four infants according to their gestational age. Which infant's information requires correction? 1. preterm 33 w 2. fullterm 40 w 3. late preterm 38 4. postterm 43

1 Infant 1 2 Infant 2 Correct 3 Infant 3 4 Infant 4 Infants who are born between 34 and 36 6/7 weeks of gestation are known as late-preterm infants, not infants who are born at 38 weeks of gestational age. An infant who is born before completion of 37 weeks of gestational age is known as a preterm infant. An infant who is born between 38 and 42 weeks of gestational age is known as a full-term infant. An infant who is born after 42 weeks of gestational age is known as a postterm infant.

The nurse is teaching a group of parents about the side effects of vaccines. Which side effect should the nurse include in teaching about the Haemophilus influenzae (Hib) vaccine?

1 Lethargy 2 Urticaria 3 Generalized rash Correct 4 Low-grade fever The Hib vaccine may cause a low-grade fever. Lethargy is not expected. Urticaria is more likely to occur with the tetanus and pertussis vaccines. There may be a mild reaction at the injection site, but a generalized rash is not expected.

An infant is admitted to the hospital with gastroenteritis. The infant vomits shortly after admission. Under standard precautions, what protective equipment should the nurse wear when cleaning the infant after the vomiting episode?

1 Mask 2 Gown 3 Face shield Correct 4 Pair of gloves Gloves should be worn when the nurse is exposed to blood and body fluids; this provides a barrier and protects the nurse. A mask, face shield, or goggles are not required unless the vomiting is projectile in nature. A gown is necessary only if there is a risk of contamination of the nurse's clothing.

The nurse is performing an auditory test that is specifically used in toddlers. Which procedure is appropriate when performing the test?

1 Observing the child's response to each sound 2 Placing electrodes on the child's head to detect auditory stimuli Correct 3 Asking the child to touch a toy every time the sound is heard Incorrect 4 Asking the child to respond in some way when the tone is heard in the earphone The auditory test used specifically in toddlers is play audiometry. The test uses an audiometer to transmit sounds at different volumes and pitches. During this test, the toddler is asked to do something with a toy, such as touching or moving it, each time the sound is heard. Behavioral audiometry is used in infants. During this test, the nurse observes the child's behavior in response to certain sounds heard through speakers or earphones. Auditory brainstem response (ABR) is used in newborns. During this test, electrodes are placed on a child's head that detect auditory stimuli presented though earphones one ear at a time. Pure tone audiometry is used in children and adolescents. This test uses an audiometer that produces sounds at different volumes and pitches in the child's ears. The child is asked to respond in some way when the tone is heard in the earphone.

Piaget Which statement is true about Piaget's theory of cognitive development?

1 Piaget's theory includes five periods that are related to age. Incorrect 2 In the late preoperational stage, the children experience animism. 3 In the preoperational stage, children are able to perform mental operations. Correct 4 During the sensorimotor stage, infants develop an action pattern for dealing with their environment. According to Piaget's theory, during the sensorimotor stage, infants develop a schema or action pattern for dealing with the environment. Piaget's theory includes four periods which are related to age. In the early preoperational stage, children experience animism. During the concrete operations stage, children are able to perform mental operations. Test-Taking Tip: If you can eliminate any responses as incorrect based on your knowledge, you will not be guessing randomly but will be exercising "informed guessing."

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action?

1 Returning the aspirate and withholding the feeding 2 Discarding the aspirate and administering the full feeding Correct 3 Returning the aspirate and subtracting the amount of the aspirate from the feeding 4 Discarding the aspirate and adding an equal amount of normal saline solution to the feeding The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance. STUDY TIP: Enhance your organizational skills by developing a checklist and creating ways to improve your ability to retain information, such as using index cards with essential data, which are easy to carry and review whenever you have a spare moment.

A nurse plans to discuss childhood nutrition with a group of parents whose children have Down syndrome in an attempt to minimize a common nutritional problem. What problem should be addressed?

1 Rickets Correct 2 Obesity 3 Anemia 4 Rumination Obesity is a common nutritional problem of children with Down syndrome. It is thought to be related to excessive caloric intake and impaired growth. Rickets is a nutritional disorder related to vitamin D deficiency; it is usually not encountered in these children. Anemia is the most common nutritional problem in children with iron deficiency. Rumination is an eating disorder of infancy characterized by repeated regurgitation without a gastrointestinal illness. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.

During physical examination of a 3-year-old child, the nurse finds that the child has only 15 teeth. Which food substances should be included in the child's diet to promote tooth formation? Select all that apply.

1 Soy Correct 2 Milk 3 Legumes Correct 4 Boiled egg 5 Fruits and vegetables A 3-year-old child normally has approximately 20 teeth. The presence of only 15 teeth indicates calcium deficiency. Milk is rich in calcium. Eggs are also a good source of calcium. Soy and legumes are rich in protein and help build muscle mass. Fruits and vegetables are good sources of vitamins and minerals and increase immunity. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A 3-month-old infant with chronic constipation has a tentative diagnosis of Hirschsprung disease. What definitive diagnostic test does the nurse expect to prepare the infant for?

1 Sweat test 2 Guthrie test Correct 3 Rectal biopsy 4 Blood glucose level During a rectal biopsy a specimen is obtained and examined for the absence of ganglion cells. Hirschsprung disease is also known as congenital aganglionic megacolon. A sweat test is performed to determine the presence of cystic fibrosis. The Guthrie test is performed on a neonate to determine the presence of inborn errors of metabolism. The blood glucose level is unrelated to the diagnosis of Hirschsprung disease.

A 4-week-old infant is admitted to the pediatric unit for cleft lip repair. The nursing assistant asks the nurse why the repair is being done at this age. What is the best response the nurse can give as to why cleft lip repair is performed so soon?

1 Tends to obstruct breathing 2 Can cause severe feeding problems 3 May cause respiratory tract infections Correct 4 Has an emotional effect on the parents The visual effect of the cleft lip on the parents may significantly affect the parent-child attachment process and is often considered a reason for early surgical intervention. The infant also uses the nose to breathe; a cleft lip does not obstruct breathing. Feeding may be accomplished with the use of specially designed bottles and nipples; this is not, by itself, an indication for early surgery. Precautions other than surgery can be taken to prevent ear and upper respiratory tract infections.

What gross motor skill is found in children between two to four months of age?

1 The child can creep on its hands and knees. 2 The child has predominant inborn reflexes. 3 The child can sit alone without any kind of support. Correct 4 The child can bear weight on forearms when prone. A child between two and four months of age is able to bear his or her weight on the forearms when in the prone position. A child between eight and 10 months of age can creep on their hands and knees. A child between birth and one month has predominant inborn reflexes. A child between six and eight months of age can sit alone without support

A father takes his two-year-old to another child's birthday party. The child resists entering into the party hall and refuses to play with the other kids. The child prefers to sit on the father's lap and watch the other children. What is the temperament of the child according to Stella Chess and Alexander Thomas's longitudinal study?

1 The easy child 2 The difficult child 3 The hyperactive child Correct 4 The slow to warm-up child A slow to warm-up child tends to be uneasy or cautious in new situations or around unfamiliar people. They react negatively with mild intensity to new stimuli. An easy child is open and adaptable to change and displays a mild-to-moderately intense mood that is typically positive. A difficult child adapts slowly to new routines, people, or situations. They have intense mood expressions with negative behavior. A hyperactive child usually has problems concentrating and paying attention. Test-Taking Tip: Read carefully and answer the question asked; pay attention to specific details in the question.

Who should the nurse include as the authority when providing education to the parents of a 7-year-old client related to moral development?

1 The school-age child 2 The school-age child's peers 3 Any higher power the child believes in Correct 4 Any adult with authority over the child When a school-age child and an adult differ in judging an act, the adult is right. The school-age child, the child's peers, and a higher power that the child believes in are not authorities to moral development of the school-age client.

What clinical finding does a nurse expect when assessing a 4-month-old infant with gastroenteritis and moderate dehydration?

1 Urine output of 50 mL/hr Correct 2 Depressed anterior fontanel 3 History of allergies to certain formulas 4 Capillary refill time of less than 2 seconds A depressed anterior fontanel is a classic sign of moderate dehydration in infants that results from a decrease in cerebrospinal fluid. Urine output of 50 mL/hr indicates adequate hydration; output will be decreased in dehydration. A history of allergies to certain formulas is unrelated to fluid loss from gastroenteritis. Capillary refill time of less than 2 seconds is an expected capillary refill time and is not indicative of moderate dehydration. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. Yo

An infant has a plaster cast applied for clubfoot correction. What nursing intervention will hasten drying of the cast?

1 Using a blow dryer 2 Opening the window Correct 3 Exposing the casted extremity 4 Covering the cast with a light sheet Exposing the casted extremity is the safest way to dry the cast evenly. With a blow dryer, the cast may dry on the outside but remain damp within; it also presents the danger of burning the child. Opening the window may create a draft and be uncomfortable for the child. Covering the cast with a light sheet will impede the circulation of air and delay drying.

During assessment, the nurse asks a client about developmental milestones such as the age at which thelarche and menarche occurred. The nurse determines that the client experienced pubertal delay. Which finding in the client's history supports the nurse's conclusion?

1 Weight increased by 8 to 12 kg. 2 Menarche occurred 2 years after thelarche. Correct 3 Breast development occurred by 15 years of age. 4 Growth in height stopped 2 years after menarche. When the development of breasts has not occurred by 13 years of age in girls, it is considered pubertal delay. An increase in weight between 7 and 25 kg is considered normal during the growth spurt period. The occurrence of menarche within 2 years of onset of breast development, or thelarche, is a normal finding. Generally in girls, growth in height stops 2 to 2.5 years after menarche.

A nurse is discussing the diet of an 8-month-old infant with the parents. Which foods can an infant of this age on a regular diet safely be fed? Select all that apply.

1 Whole milk Correct 2 Pureed pears Correct 3 Pureed carrots 4 Soft-boiled eggs Correct 5 Mashed sweet potatoes Pureed pears, pureed carrots, and mashed sweet potatoes are easily digested foods that are usually introduced by 6 months of age. Breast milk or formula, not whole milk, is recommended for the first year of life. It is preferred that eggs be introduced toward the end of the first year because they may produce an allergic response.

The nurse notes that the peak height velocity (PHV) for an 11-year-old female has occurred since the last health maintenance visit. Which assessment question should the nurse ask the adolescent based on this data?

Correct 1 "Have you begun to menstruate?" 2 "How tall do you think you will get?" 3 "What do you typically eat in a normal day?" 4 "Are you taller than most of the other girls in your class?" An accelerated rate of linear growth is referred to as PHV. When this occurs for a school-age or adolescent female client, it is a predictor for menarche; therefore, asking the client if she has begun to menstruate is an appropriate assessment question. Typically, menarche begins 6 to 12 months after PHV. The other questions are not inappropriate, but they are not assessment questions that should be asked based on the current client data

A new mother is concerned that her 1-month-old infant is nursing every 2 hours. Which response by the nurse is most appropriate?

Correct 1 "It's common for newborns to nurse this often. Let's talk about how you're adjusting with the new baby." 2 "Breast milk is easily digested; giving your infant a little rice cereal will keep him full longer." 3 "It sounds as though your baby is a little spoiled; try to resist feeding more often than every 4 hours." 4 "You may not be producing enough milk; it'll be important for you to supplement feedings with formula." Newborns typically nurse every 2 to 3 hours. Although breast milk is easily digested, feeding solids to an infant is not recommended at this age. Feeding satisfies a fundamental need; one does not spoil an infant by nursing as needed. Adequate intake is evidenced in infant weight gain and adequate urinary and bowel elimination. Supplementing feedings with formula may lead to decreased milk production. Test-Taking Tip: Do not read information into questions, and avoid speculating. Reading into questions creates errors in judgment.

Which statements related to relationships with family should the nurse include in a teaching session for a school-age client and parents? Select all that apply.

Correct 1 "Parents of school-age children must learn to let go of control." 2 "Strict discipline is the priority over understanding and tolerance." Correct 3 "Peer groups are highly influential during this stage of development." Correct 4 "Your child may wish to be more involved with peer activities than family activities." Correct 5 "When a conflict between peers and parents occurs, family values will predominate." During the school-age stage of development, parents must learn to let go of control; peer groups are highly influential during this stage of development; the parents must also understand that their child may wish to be more involved with peer activities rather than family activities; and when a conflict occurs between the school-age child's peers and parents their family's values will predominate. Parents of a school-age child best serve their child's interests with understanding and tolerance rather than strict discipline.

A nurse is educating the parents of a preschooler about the importance of play in the development of their child. Which statements should the nurse include for adequate teaching? Select all that apply.

Correct 1 "Playing helps the child to socialize with others." Correct 2 "Pretend play allows children to learn to understand others." Correct 3 "Playing helps the child to release frustration." 4 "If the child fantasizes about imaginary playmates, introduce him or her to reality." 5 "The child should completely avoid television, video games, and computer programs." A child should be encouraged to play because this activity helps the child to socialize with others, learn to understand other points of view, develop skills in solving social problems, and release frustration. Imaginary playmates are a sign of health and allow the child to distinguish between reality and fantasy; this type of play should not be discouraged. Television, video games, and computer programs also support development and the learning of basic skills. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

A nurse is obtaining the health history of a 7-month-old who has had repeated episodes of otitis media. What question is most important for the nurse to include in the interview with the mother?

Correct 1 "Please describe your child's feeding pattern." Incorrect 2 "Tell me how often your child has had ear infections." 3 "What medicine do you give your child for the ear infections?" 4 "Do any of your children other than your baby have this problem?" It is important to determine the infant's feeding pattern, because drinking formula from a bottle while in a recumbent position may lead to pooling of fluid in the pharyngeal cavity, which hinders eustachian tube drainage. Although knowing the frequency of ear infections is important, the factor that precipitated the otitis media is more significant. Although it is important to determine what medication has been given for otitis media, it is more important to determine the cause of this infection. Asking about the other family members is irrelevant, because otitis media is an inflammatory response, not a hereditary disease. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."

The nurse is assessing an 8-year-old child who suffers from encopresis. Which advice given by the nurse provides effective treatment for the child? Select all that apply.

Correct 1 "You should drink lots of fluid." 2 "You should include milk in your diet." 3 "You should delay the urge to defecate." Correct 4 "You should include cereals in your diet." Correct 5 "You should eat fresh fruit for breakfast." Encopresis is the voluntary or involuntary passage of feces of varying consistency in inappropriate settings. The child with encopresis usually has constipation. Therefore cereals should be included in the child's diet, because they contain high amounts of fiber, which helps in the formation and passage of regular stools. Sufficient water is necessary to prevent constipation or pain during defecation. Therefore, the nurse instructs the child to drink sufficient fluids. Fruits are also rich fiber sources and ease the process of defecation. Milk increases the risk of uncontrolled defecation. Therefore, the nurse instructs the child to avoid milk. Delaying defecation results in water absorption from the stool, which may cause constipation and increased pain during defecation.

The nurse is preparing to assess several clients at a pediatric clinic. Which client would require a developmental screening versus developmental surveillance during a scheduled health maintenance visit?

Correct 1 A 9-month-old infant Incorrect 2 A 2-week-old newborn 3 A 15-month-old toddler 4 A 4-year-old preschooler The nurse would conduct a developmental screening for the 9-month-old infant during a scheduled health maintenance visit. The 2-week-old newborn, the 15-month-old toddler, and the 4-year-old preschooler would all require developmental surveillance during a health maintenance visit.

The nurse is teaching an adolescent about the different methods of contraception. Which statement made by the adolescent indicates a need for further teaching?

Correct 1 A diaphragm is a soft rubber dome and requires nothing else. 2 Condoms require consistent use and may cause decreased spontaneity. 3 Lea's shield is less effective in women who have had previous deliveries. 4 A cervical cap is contraindicated in women with a history of toxic shock syndrome. A diaphragm is a latex or rubber dome-shaped cup contraceptive device used along with spermicidal jelly to cover the cervical opening. A condom covers the penis and traps the sperm. Condoms need to be used consistently and may cause decreased spontaneity. Lea's shield is a reusable vaginal contraceptive that is elliptical in shape. However, it is not effective in women who have already delivered a baby, as the vagina does not remain elliptical. The cervical cap should not be used by women who have a history of toxic shock syndrome. STUDY TIP: The old standbys of enough sleep and adequate nutritional intake also help keep excessive stress at bay. Although nursing students learn about the body's energy needs in anatomy and physiology classes, somehow they tend to forget that glucose is necessary for brain cells to work. Skipping breakfast or lunch or surviving on junk food puts the brain at a disadvantage

Which should the nurse include in the plan of care for an adolescent who is diagnosed with a chronic illness?

Correct 1 Achieving independence from family 2 Forming same-sex peer relationships 3 Learning through concrete operations 4 Developing a sense of accomplishment The nurse should include achieving independence from family in the plan of care for an adolescent client who is diagnosed with a chronic illness. Forming same-sex peer relationships, learning through concrete operations, and developing a sense of accomplishment should be included in the plan of care for a school-age, not adolescent, client with a chronic illness.

The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response?

Correct 1 As evidence of hearing loss 2 As an effect of vision deficits 3 As developmentally appropriate 4 As evidence of a low-normal hearing range By 3 to 4 months of age an infant should localize sound by looking in the direction of the sound. The nurse's observation does not provide information about the infant's ability to see. This response indicates that the infant's hearing is not developmentally appropriate. Low-normal hearing range is not within the norm for this age group.

After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action?

Correct 1 Assessing the infant's status 2 Giving the infant a mild sedative 3 Connecting the nasogastric tube to wall suction 4 Placing the intravenous tubing through an infusion pump Assessment, the first step of the nursing process, is the priority because it influences all future interventions. The infant's respiratory status and vital signs should be assessed before a sedative is administered. Although it is important to attach the nasogastric tube to a suction device, this may be done after the infant's status has been assessed. Although it is important to connect the intravenous line to a pump, this may also be done after the infant's status has been assessed.

Which activities should the nurse recommend to a middle-age adult client to find a sense of fulfillment, according to Erikson? Select all that apply.

Correct 1 Attending church functions 2 Visiting adult children in their homes Correct 3 Becoming involved at a local hospital Correct 4 Volunteering to coach for a grandchild's soccer team 5 Allowing independent decision-making when hospitalized According to Erikson, middle-aged persons often find a sense of fulfillment by volunteering in a local school, hospital, or church; therefore, the nurse would recommend that the client attend church functions, become involved at a local hospital, and volunteer to coach a grandchild's soccer team. All of these suggestions would allow the client to find a sense of fulfillment. Visiting adult children in their homes and allowing independent decision-making when hospitalized are not recommendations that will allow the client to find a sense of fulfillment.

A parent of a 6-month-old infant asks the nurse which foods should be introduced first. What is the best response by the nurse?

Correct 1 Baby cereals 2 Soft-boiled eggs 3 Fruits and puddings 4 Meats and vegetables The first solid food added to the infant's diet should be easily digestible; fortified cereals are easy to digest and are a rich source of iron. Eggs are one of the last foods to be added to the diet because they may cause an allergic reaction. Puddings contain eggs, which are one of the last foods to be added to the diet because they may cause allergic reactions. Meats and vegetables are more difficult to digest than cereal is. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt?

Correct 1 By palpating the anterior fontanel 2 By determining the frequency of voiding 3 By assessing the child for periorbital edema 4 By assessing the symmetry of the Moro reflex A bulging fontanel is the most significant sign of increased intracranial pressure in an infant. Periorbital edema, the frequency of voiding, and the symmetry of the Moro reflex are not indicators of increased intracranial pressure.

According to Piaget, which data does the nurse expect for a school-age child during the nursing assessment process? Select all that apply.

Correct 1 Classifying objects Correct 2 Understanding reversibility 3 Having theoretical thoughts Correct 4 Describing a process without actually doing it 5 Believing personal actions are constantly being scrutinized Classifying objects, understanding reversibility, and describing a process without actually doing it are data the nurse would expect for a school-age child according to Piaget's cognitive developmental theory. Having theoretical thoughts and believing personal actions are constantly being scrutinized are not expected for the school-age child.

A mother brings her 9-month-old infant to the clinic. The nurse is familiar with the mother's culture and knows that belly binding to prevent extrusion of the umbilicus is a common practice. The nurse accepts the mother's cultural beliefs but is concerned for the infant's safety. What variation of belly binding does the nurse discourage?

Correct 1 Coin in the umbilicus 2 Tight diaper over the umbilicus 3 Binder that encircles the umbilicus 4 Adhesive tape across the umbilicus A coin may be dislodged, allowing the infant to put it in his or her the mouth, resulting in a safety issue. A diaper fastened tightly around the waist, a binder, or adhesive tape over the umbilicus will not endanger the infant. Cultural beliefs that do not place the infant at risk should not be discouraged.

Which of the following are congenital anomalies or birth defects seen in children? Select all that apply.

Correct 1 Dysplasias Correct 2 Disruptions Incorrect 3 Teratogens Correct 4 Deformations Correct 5 Malformations Dysplasias are caused by abnormal organization of cells into a particular tissue type. Disruptions are sometimes seen in a child from the breakdown of previously normal tissue. Deformations may be seen in a child at birth and are caused by extrinsic mechanical forces on normally developing tissue. Malformations are abnormal body parts caused by an abnormal developmental process. Teratogens are agents such as drugs, warfarin, alcohol, or bacteria that cause birth defects in a child

What dietary information should the nurse include in the teaching plan for parents of an infant with galactosemia? Select all that apply.

Correct 1 Eliminate milk. 2 Substitute meat for eggs. Correct 3 Provide soybean-based formulas. 4 Avoid baby cereals containing wheat flour. 5 Give prescribed pancreatic enzyme capsules with meals. Milk and dairy products are high in lactose content and should be eliminated from the diet. Soybean-based formulas are permissible because they do not contain lactose. Both meat and eggs are permitted because neither contains lactose. Cereals containing wheat products are eliminated from the diet of children with celiac disease. Pancreatic enzymes are prescribed for children with cystic fibrosis, not galactosemia.

Which nursing intervention provides the most support to the parents of an infant with an obvious physical anomaly?

Correct 1 Encouraging them to express their concerns 2 Discouraging them from talking about their baby 3 Encouraging them not to worry because the anomaly can be repaired 4 Showing them postoperative photographs of infants who had a similar anomaly Encouraging parents to express their concerns helps and encourages them to put their fears and feelings into words. Once these sentiments are expressed, they can then be examined and addressed. Discouraging the parents from talking about their baby will not help them cope with the problem, nor will it demonstrate the supportive, empathetic role of the nurse. Encouraging them not to worry because the anomaly can be repaired lacks insight, and parents will worry about their infant anyway. Showing postoperative photographs of infants who had a similar anomaly may or may not be helpful.

A nurse in the child health clinic is assessing a 9-month-old infant. What developmental findings does the nurse expect? Select all that apply.

Correct 1 Enjoys push-pull toys Correct 2 Sits steadily without support 3 Feeds self with a baby spoon Correct 4 Responds to simple commands Incorrect 5 Has a vocabulary of two words Nine-month-old infants enjoy the interaction associated with push-pull toys. Sitting steadily occurs by 8 months of age. Nine-month-old infants respond to simple commands such as "No" and try to please their parents. Self-feeding is accomplished by 2-year-old children, not infants. A two- to three-word vocabulary is expected of a 12-month-old child.

During change-of-shift report, the oncoming nurse receives information about a 14-month-old infant who underwent cleft palate repair the previous day. The child is currently on a full-liquid diet from cups only. No spoons or straws are allowed in the child's mouth. In addition, the child has elbow restraints on both arms. What care should the nurse include during the course of the shift?

Correct 1 Finishing each meal with a drink of water 2 Using a soft toothbrush to brush the child's teeth 3 Encouraging crying for 10 minutes periodically to promote respiratory function 4 Removing both restraints simultaneously every 2 hours to promote arm mobility Following each full liquid meal with water will flush debris from the palate sutures. Toothbrushing should be prohibited during the postoperative period, because a sudden movement by the child could traumatize the suture line. Although short periods of crying will promote deep breathing, 10 minutes of crying will stress the suture line and lead to emotional trauma. Restraints should be removed one at a time every 2 hours for range-of-motion exercise and inspection of the skin. If they are removed simultaneously, the child could touch the suture line with one hand while the nurse is controlling the movement of the other arm.

At which stage of Kohlberg's theory does an individual want to fulfill the expectations of one's immediate group?

Correct 1 Good boy-nice girl orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation The good boy-good girl orientation stage involves an individual who wants to win the approval and maintain the expectations of one's immediate group. During the society-maintaining orientation stage, an individual expands focus from a relationship with others to societal concerns. The instrumental relativist orientation stage involves a child who wants to follow his or her parent's rules. The universal ethical principle orientation stage defines "right" by the decision of conscience according to self-chosen ethical principles.

The parents of a sick infant talk with a nurse about their baby. One says, "I'm so upset; I didn't realize that our baby was ill." What major indication of illness in an infant should the nurse explain to the parent?

Correct 1 Grunting respirations 2 Excessive perspiration 3 Longer periods of sleep 4 Crying immediately after feedings Grunting and rapid respirations are signs of respiratory distress in an infant. Grunting is a compensatory mechanism by which the infant attempts to keep air in the alveoli to increase arterial oxygenation; increased respirations increase oxygen and carbon dioxide exchange. Sweating in infants usually is scant because of immature function of the exocrine glands; profuse sweating is rarely seen in a sick infant. Longer periods of sleep are not necessarily a sign of illness, nor is crying immediately after feedings. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.

A student nurse compares the sources of stress in both 7-year-olds and 12-year-olds. Which source of stress is prevalent in children of both these age groups?

Correct 1 Idols 2 Health 3 Money 4 Confusion Idols are a source of stress for both 7-year-old and 12-year-old children. The 7-year-old has a desire to be more like an admired idol. The 12-year-old continues hero worshipping. Health is a source of stress for 12-year-olds and some may become hypochondriacs during this period of development. Health is not a source of stress for 7-year-olds. Money can be a source of stress for the 12-year-old. This child is anxious to earn and handle money but often uses poor judgment. Money is not yet a matter of concern for the 7-year-old. Too much freedom can create confusion in a 12-year-old and can cause the child to flounder. A 7-year-old does not usually have much freedom and, thereby, does not experience the accompanying stress.

An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode. In what position should the nurse place the infant to relieve the cyanosis and dyspnea?

Correct 1 Knee-chest 2 Orthopneic 3 Lateral Sims 4 Semi-Fowler Flexing the hips and knees decreases venous return to the heart from the legs. When venous return to the heart is decreased, the cardiac workload is decreased. Although the orthopneic position reduces pressure of the abdominal organs on the diaphragm, it does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart. The lateral Sims position does not reduce venous return to the heart. It does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart. Although the semi-Fowler position reduces pressure of the abdominal organs on the diaphragm, it does not put enough pressure on the femoral veins and vena cava to sufficiently reduce venous return to the heart. Test-Taking Tip: When using this program, be sure to note if you guess at an answer. This will permit you to identify areas that need further review. Also it will help you to see how correct your guessing can be.

A 3-month-old infant who has a 3-day history of diarrhea is admitted to the pediatric unit. The nurse obtains the infant's vital signs, performs a physical assessment, and reviews the infant's arterial blood gas results. Which acid-base imbalance does the nurse suspect? ABG- pH 7.3 PCO3 35 HCO3 17 pulse 155 resp. 40

Correct 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis The pH indicates acidosis, not alkalosis; the HCO 3 - level is further from the expected range than is the Pco 2 level, indicating a metabolic, not respiratory, origin (losses from diarrhea).

A nurse is teaching the parents of an infant with eczema about the foods that are most allergenic. What foods should the nurse instruct the parents to eliminate from the diet? Select all that apply.

Correct 1 Milk Correct 2 Eggs 3 Apples Correct 4 Peanuts 5 Bananas Milk and eggs contain protein to which the eczematous child may be allergic. Peanuts are highly allergenic. Apples and bananas rarely cause an allergic reaction.

A nurse sees another health team member cover an infant with a blanket to prevent heat loss. What heat loss mechanism is being minimized by this action?

Correct 1 Radiation 2 Conduction 3 Active transport 4 Fluid vaporization Radiation, or the transfer of heat from a warm object to the atmosphere, is prevented by covering the child with a blanket. Reducing body surface area (e.g., flexing all extremities in toward the body) also limits heat loss through radiation. Conduction is the transfer of heat from one molecule to another with contact between the two. Active transport is not related to loss of heat; this is a process that moves ions or molecules across a cell membrane against a concentration gradient. Vaporization is the conversion of liquid or solid into a vapor; it occurs when a person is perspiring. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

Which stage of Lawrence Kohlberg's theory of moral development is associated with a person following a law even if it is discriminatory to a racial group?

Correct 1 Social contract orientation 2 Society-maintaining orientation 3 Instrumental relativist orientation 4 Universal ethical principle orientation A person in the social contract orientation stage follows laws even if they are not fair to a certain racial group. During the society-maintaining orientation stage, an individual expands his or her focus from a relationship with others to societal concerns. During the instrumental relativist orientation stage, the decision to do something morally right is based on satisfying one's own needs and occasionally the needs of others. An individual in the universal ethical principle orientation stage may not follow a law if it does not seem fair to a particular racial group.

An infant with a diagnosis of hydrocephalus has just had a ventriculoperitoneal shunt inserted. In what position should the nurse place the infant? .

Correct 1 Supine on the unaffected side 2 Side-lying on the affected side Incorrect 3 Head elevated at 45 degrees on the affected side 4 Head elevated at 90 degrees on the unaffected side Placing the infant flat will prevent complications from too-rapid reduction of intracranial fluid; placing the infant on the unaffected side will prevent pressure on the shunt valve. Placing the infant on the affected side will put pressure on the shunt valve, which may cause it to become obstructed, interfering with the outflow of cerebrospinal fluid. Raising the head of the bed will allow a too-rapid reduction in cerebrospinal fluid, which may cause the cerebral cortex to pull away from the dura, resulting in a subdural hematoma. Placing the infant on the affected side will put pressure on the shunt valve. Elevating the head to 90 degrees will permit too rapid a reduction in cerebrospinal fluid. Test-Taking Tip: Do not spend too much time on one question, because it can compromise your overall performance. There is no deduction for incorrect answers, so you are not penalized for guessing. You cannot leave an answer blank; therefore, guess. Go for it! Remember: You do not have to get all the questions correct to pass

The nurse is assessing an 8-month-old child's gross motor development. Which action by the child indicates late development?

Correct 1 The child is unable to stand by holding onto furniture. Incorrect 2 The child cannot change from a prone to a sitting position. 3 The child cannot sit down from a standing position without help. 4 The child cannot sit steadily on the floor for a prolonged period of time. At 8 months of age the child should be able to stand by holding onto furniture, because the child readily bears weight on the legs when supported. When a child is 10 months old, the child can change from a prone to a sitting position. When a child is 12 months old, the child is able to sit down from a standing position without any help. When a child is at least 9 months old, the child can sit steadily on the floor for a prolonged period of time.

When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?

Correct 1 They may occur in minor illnesses. 2 The cause is usually readily identified. 3 They usually do not occur during the toddler years. 4 The frequency of occurrence is greater in females than males. Febrile seizures are usually not associated with major neurologic problems. Between 95% and 98% of these children do not experience epilepsy or other neurologic problems. The cause of febrile seizures is still uncertain. Most febrile seizures occur after 6 months of age and before age 3 years, with the average age of onset between 18 and 22 months. Boys are affected about twice as frequently as girls.

A 9-month-old infant who appears well nourished, alert, and happy is brought to the well-baby clinic for a routine physical examination. Using Erikson's theory of development, what task does the nurse determine that the infant is in the process of achieving?

Correct 1 Trust 2 Industry 3 Initiative 4 Autonomy Trust is developed if the infant's needs are being met by the caregivers. The task of industry should be successfully completed during the childhood years (6 to 12 years of age). The task of initiative should be successfully completed between 3 and 6 years of age. The stage of autonomy is successfully completed during the toddler years (1 to 3 years of age).

The parents of an infant with newly diagnosed cystic fibrosis ask a nurse what causes the foul-smelling, frothy stool. What is the best response by the nurse?

Correct 1 Undigested fat 2 Sodium and chloride 3 Partially digested carbohydrates 4 Lipase, trypsin, and amylase release Because of a lack of the pancreatic enzyme lipase, fats remain unabsorbed and are excreted in excessive amounts in the stool. Sodium, chloride, and partially digested carbohydrates do not cause the typical characteristics of the stools. Lipase, trypsin, and amylase are the pancreatic enzymes whose passage into the intestine is prevented by blocked pancreatic ducts. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. Similarly, words such as only, always, never, and all in the alternatives are frequently evidence of a wrong response. As in life, no real absolutes exist in nursing; however, every rule has its exceptions, so answer with care.

Which symptoms present in a child indicate Turner syndrome? Select all that apply.

Correct 1 Webbed neck 2 Impaired language 3 Tall stature with long legs Correct 4 Low position of posterior hairline Correct 5 Shield-shaped chest with wide space between the nipples Turner syndrome is a chromosomal abnormality seen in females in which an X chromosome is partly or completely absent. The clinical manifestations of Turner syndrome include a webbed neck, low posterior hairline, and shield-shaped chest with wide space between the nipples. Impaired language skills are seen in clients with triple X or superfemale syndrome. The client with Turner syndrome has short stature. Tall stature with long legs is a finding in Klinefelter syndrome.

A parent tells the nurse, "My 9-month-old doesn't have the same strong grasp that she had when she was born, and she's not startled by loud noises anymore." How should the nurse explain these changes in behavior?

Incorrect 1 "Let me check these responses before deciding how to proceed." 2 "When these responses fail, it may indicate a developmental delay." 3 "The baby needs more sensory stimulation to get these responses back." Correct 4 "Those responses are replaced by voluntary activity around 5 months of age." Touching the palm of a newborn causes flexion of the fingers (grasp reflex ); this response usually diminishes after 3 months of age. An unexpected loud noise causes the newborn to abduct the extremities and then flex the elbows (startle reflex); this response usually disappears by 4 months of age. Persistence of primitive reflexes is usually indicative of a developmental delay. It is not necessary to gather more data, because these changes are consistent with expected growth and development. The data do not support the conclusion that the child is developmentally delayed, and saying so may cause needless concern. Sensory stimulation at this age is directed toward experiences to add new motor, language, and social skills.

The nurse is conducting a health maintenance visit for a 5-year-old client who will begin kindergarten in the fall. Which teaching statement should the nurse include for this child, who is considered slow to warm up?

Incorrect 1 "Your child should adapt without any issues." 2 "You should expect minimal stress from your child." 3 "Your child would benefit from a practice run prior to riding the bus on the first day of school." Correct 4 "You should encourage your child to try new things allowing for adequate time for adaptation." Slow-to-warm-up children often exhibit discomfort when placed in new situations, such as the start of kindergarten. The nurse would encourage this child's parents to encourage their child to try new things while allowing adequate time for adaptation. The easy, not slow-to-warm-up, child is expected to adapt to kindergarten without any issues and experience minimal stress. The difficult, not slow-to-warm-up, child would benefit from a practice run to riding the school bus on the first day of school.

A complete blood count is prescribed for a 5-month-old infant with tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?

Incorrect 1 Anemia Correct 2 Polycythemia 3 Agranulocytosis 4 Thrombocytopenia The body responds to the chronic hypoxia caused by the heart defect by increasing the production of red blood cells (RBCs) in an attempt to increase the oxygen-carrying capacity of the blood. The RBC count will be increased because the body increases erythrocyte production in an attempt to make more cells available to carry oxygen. Agranulocytosis does not result from hypoxia; it occurs when the white blood cell count decreases to a very low level and neutropenia becomes pronounced. Thrombocytopenia (low platelet count) does not result from hypoxia; it occurs in disease processes in which platelet production is suppressed, platelet survival is decreased, or platelet destruction is increased

Which nursing action is appropriate to determine conservation for the 9-year-old client who has mastered the expected conservation for age prior to the current health maintenance visit?

Incorrect 1 Asking the child to compare mass 2 Asking the child to compare length Correct 3 Asking the child to compare weight 4 Asking the child to compare numbers The nurse would assess for conservation of weight for the 9-year-old school-age client who has mastered the expected conservation for age up until the current visit. Conservation of mass is expected between 5 and 7 years of age. Conservation of length is expected at 6 to 7 years of age. Conservation of numbers is expected at 5 to 7 years of ag

A 3-month-old infant with severe developmental dysplasia of the hip has a hip spica cast applied. What instruction should the nurse give the parents to help prevent a serious complication?

Incorrect 1 Change diapers frequently. 2 Decrease the number of feedings per day. Correct 3 Call the primary healthcare provider if a foul smell is detected. 4 Avoid turning the child from the prone to the supine position. A foul smell emanating from the cast indicates the development of an infection and necessitates immediate intervention. Soiling of the cast with excreta, although problematic, is not a serious complication. Decreasing the number of feedings per day is not necessary, nor is it desirable. The infant's position should be changed frequently.

Which finding related to a school-age client's vital signs should the nurse anticipate during the assessment process?

Incorrect 1 Increased heart rate Correct 2 Increased blood pressure 3 Increased respiratory rate 4 Increased body temperature During the school-age stage of development, the nurse anticipates an increase in blood pressure. Other findings the nurse anticipates include a decreased heart rate and respiratory rate; neither of these values are increased during the school-age stage of development. Body temperature does not change

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures?

Incorrect 1 Mobility will be delayed if correction is postponed. 2 Traction is effective if it is used before toddlerhood. 3 Infants are easier to manage in spica casts than are toddlers. Correct 4 Infants' cartilaginous hip joints promote molding of the acetabulum. The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment. Test-Taking Tip: If the question asks for an immediate action or response, all the answers may be correct, so base your selection on identified priorities for action.

Which activity should the nurse encourage to enhance a toddler's ability to learn through sensorimotor experiences?

Incorrect 1 Play dates 2 Bottle holding Correct 3 Finger-painting 4 Trips to the park Finger-painting is an age-appropriate activity for a toddler in order to enhance learning through sensorimotor experiences. Play dates are encouraged for the preschool-age child. Bottle holding is an age-appropriate activity for an infant in order to enhance learning through sensorimotor experiences. Trips to the park are an age appropriate activity for a preschool-age child.

When assessing the development of a school-age child, the nurse concludes that the child has normal development according to Fowler's spiritual development. Which behavior helped the nurse reach this conclusion?

Incorrect 1 The child imitates the religious gestures of elders. 2 The child does not differentiate between right and wrong actions. 3 The child has spiritual disappointment and modifies religious practices. Correct 4 The child believes God will punish bad behavior and reward good behavior. The school-age child will have a developing conscience. Therefore the child believes that God will punish bad behavior and reward good behavior. This indicates that the child is in the mythical-literal stage of Fowler's spiritual development. A preschooler who is in the intuitive-projective stage of Fowler's spiritual development will imitate the behavior of others. An infant who is in differential stage of Fowler's development will not have a concept of right and wrong. An adolescent who is in the synthetic-convention stage of Fowler's spiritual development will be disappointed that God does not answer all prayers. Therefore the child will modify his or her religious beliefs. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience.

The parents tell the nurse that their preschooler often awakes from sleep screaming in the middle of the night. The preschooler is not easily comforted and screams if the parents try to restrain the child. What does the nurse instruct the parents?

1 "Always read a story to the child before bedtime." Correct 2 "Intervene only if necessary to protect the child from injury." 3 "Discuss counseling options with the primary health care provider." 4 "Try to wake the child and ask the child to describe the dream." Waking up screaming from sleep at night indicates sleep terrors. The nurse should advise the parents to observe the child and intervene only if there is a risk for injury. Reading a story before bedtime helps to calm the child before sleeping, but it does not ensure that the child will not have a sleep terror. There is no need for professional counseling, because sleep terrors are a common phenomenon in preschool-age children. The child is not aware of anybody's presence during a sleep terror, so it is not appropriate to wake up the child; this may cause the child to scream and thrash more.

9. The mother of a 4-month-old infant weighing 11 lb (5 kg) asks the nurse how much formula is required per day now that her baby has been weaned from the breast. The recommended caloric intake is 108 kcal/kg, and the formula contains 20 kcal/oz (20 kcal/30 mL). How much formula should the nurse tell the mother to give to her infant each day?

(108/20)5 1 21 oz (630 mL) Correct 2 27 oz (810 mL) 3 33 oz (990 mL) 4 39 oz (1170 mL) The infant's daily intake should be approximately 27 oz (810 mL). The infant weighs 11 lb (11/2.2 = 5 kg). An infant's daily caloric need is 108 kcal/kg body weight. 108 kcal × 5 kg = 540 kcal/day; because there are 20 kcal/oz, 540 ÷ 20 = 27 oz (20 kcal/30 mL, 540 ÷ 20 X 30 mL = 810 mL) . Twenty-one ounces (630 mL) is inadequate; 33 (990 mL) oz or 39 (1170 mL) oz is excessive. Test-Taking Tip: Prepare for exams when and where you are most alert and able to concentrate. If you are most alert at night, study at night. If you are most alert at 2 am, study in the early morning hours. Study where you can focus your attention and avoid distractions. This may be in the library or in a quiet corner of your home. The key point is to keep on doing what is working for you. If you are distracted or falling asleep, you may want to change when and where you are studying.

8. A mother who is visiting the pediatric clinic with her 10-month-old son tells the nurse how pleased she is with her chubby infant. She exclaims, "Look how much weight he's gained even though he drinks only orange juice! He won't drink any milk!" What is best response by the nurse?

1 "He's a little overweight." Correct 2 "Let's talk about his nutrition." 3 "Is he getting an iron supplement?" 4 "Why is he only drinking orange juice?" The nurse must determine whether the infant is eating solid foods and receiving vitamin and mineral supplements. Although orange juice contains vitamin C, it is too high in simple sugars and contains insufficient amounts of iron, calcium, and other essential vitamins and minerals. It is inappropriate to comment on the infant's weight; it is also insufficient to comment on just one aspect of the infant's dietary history. Asking why the infant is only drinking orange juice is a judgmental and accusatory question; again, it is insufficient to comment on just one aspect of the infant's diet history. Test-Taking Tip: Get a good night's sleep before an exam. Staying up all night to study before an exam rarely helps anyone. It usually interferes with the ability to concentrate.

Which statement made by the mother of a 6-month-old infant would warrant further assessment regarding the infant's fine motor skills?

1 "She loves to bang her toys on the tray of her highchair." Correct 2 "She seems lazier than my other kids because I still hold her bottle." 3 "She has discovered her feet and is constantly trying to put them in her mouth." 4 "She loves to drop things and then pick them up again so that we will clap for her." The nurse would further assess fine motor development for a 6-month-old infant who is not independently holding his or her own bottle. Banging toys together or on another surface, placing feet into the mouth, and dropping things so that he or she can pick them back up are fine motor skill expectations for the 6-month-old infant.

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements does the nurse include in the teaching plan? Select all that apply.

1 "Your child should be able to show the grasp reflex." Correct 2 "Your child should be able to coo, babble, and chuckle." Correct 3 "Your child should be able to pull at blankets or clothes." Incorrect 4 "Your child should be able to put the feet into the mouth when supine." Correct 5 "Your child's head can come up to a 45- to 90-degree angle from the table." Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

What birth weight in a neonate indicates that the infant is a very low birth weight (VLBW) infant?

1 900 g Correct 2 1300 g 3 1700 g 4 2000 g Infants whose birth weight is less than 1500 g are known as very low birth weight infants. Infants whose birth weight is less than 1000 g are known as extremely low birth weight infants. Infants whose birth weight is less than 2500 g are known as low birth weight infants.

For which pediatric client should the nurse use the Age and Stages Questionnaire (ASQ) as a developmental screening tool during a health maintenance assessment?

1 A 2-week old newborn client Correct 2 A 15-month-old toddler client 3 A 6-year-old school-age client 4 A 14-year-old adolescent client The ASQ developmental screening tool is appropriate to use for pediatric clients from 1 month to 4.5 years of age. The nurse would use this screening tool for the 15-month-old toddler. The other clients are not within the age range for the use of the ASQ screening tool.

According to Piaget's theory, which of these statements about the period of concrete operations is true?

1 A child develops a scheme for dealing with the environment. Correct 2 A child is able to describe a process without actually doing it. Incorrect 3 A child has the capacity to reason with respect to possibilities. 4 A child believes that everyone experiences the world exactly as he or she does. According to Piaget's theory, a child is able to describe a process without actually carrying it out in the concrete operations period. A child develops a scheme for dealing with the environment during the sensorimotor period. A child gains the capacity to reason with respect to possibilities during the formal operations period. A child believes that everyone experiences the world exactly as he or she does during the preoperational period.

A 2-month-old infant is being treated with sequential casts for bilateral clubfoot (talipes equinovarus). New casts have just been applied. What should the nurse evaluate to determine that circulation to the feet remains sufficient?

1 Alignment of legs on x-ray Correct 2 Warmth of the toes of both feet 3 Mobility of the knees when flexed 4 Presence of posterior tibial pulses Peripheral vascular assessment includes comparing temperature, color, sensation, mobility, capillary refill, and, if accessible, peripheral pulses. The posterior tibial pulse site is under the cast and is not accessible for palpation. Mobility of the knees when flexed is impossible, because the cast extends from the thigh to just above the toes. X-rays permit assessment of bones, not of circulation. STUDY TIP: Laughter is a great stress reliever. Watching a short program that makes you laugh, reading something funny, or sharing humor with friends helps decrease stress.

A nurse is caring for an infant with a cleft lip and palate. What information should the nurse include when teaching the parents about this diagnosis?

1 Anticipation that these children will have psychological problems 2 Emphasis that the two defects follow the laws of Mendelian genetics 3 Assurance that the defect is rare and probably will not occur twice in the same family Correct 4 Expectation that these children will have no other defect and otherwise will be healthy Children with a cleft lip and palate are otherwise healthy, and once a successful feeding technique is established they feed, gain weight, and thrive as expected, even without corrective surgery. The way in which the young child responds to these defects depends on parental responses. Mendelian laws of inheritance do not apply to these defects. These defects are familial; however, an exact pathogenesis has not been identified.

4. When does the anterior fontanel of an infant close?

1 At 4 to 10 months 2 At 8 to 12 months Correct 3 At 12 to 18 months 4 At 18 to 26 months The anterior fontanel usually closes between 12 and 18 months. Test-Taking Tip: Multiple-choice questions can be challenging because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

During a parenting class a nurse is discussing infant/toddler nutrition and ways to reduce the risk of food allergies. What food item should the nurse recommend that the parents avoid until their children are 3 years old?

1 Cow's milk 2 Soy products Correct 3 Peanut butter 4 Chocolate candy Peanut allergies tend to be very severe. To reduce the risk of peanut allergies, parents should delay their introduction into the diet until the gastrointestinal tract has matured. Cow's milk is introduced after 1 year. Although often considered hypoallergenic, soy products can cause food allergies. However, because of the infrequency of soy in the American diet, its entry is not delayed after the first year. Chocolate may be introduced after the first year of life. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best

The nurse observes bleeding into the subgaleal compartment upon reviewing a child's magnetic resonance imaging (MRI) results. What other conditions should the nurse evaluate for in the child? Select all that apply.

1 Decreased heart rate Correct 2 Decreased platelet levels 3 Decreased bilirubin levels Correct 4 Decreased hematocrit levels 5 Decreased head circumference Bleeding into the subgaleal compartment indicates subgaleal hemorrhage in an infant. Subgaleal hemorrhage is also associated with disseminated intravascular coagulation, which results in thrombocytopenia or decreased blood platelets in the body. A neonate with subgaleal hemorrhage experiences destruction of red blood cells within the hematoma; therefore the neonate will have decreased hematocrit. Subgaleal hemorrhage is characterized by tachycardia, not decreased heart rate or bradycardia. Subgaleal hemorrhage is characterized by hyperbilirubinemia because of degradation of red blood cells. A neonate with subgaleal hemorrhage shows megacephaly, not decreased head circumference.

Which topic should the nurse include in the anticipatory guidance provided to the parents of a 12-year-old client during a scheduled health maintenance visit?

1 Erratic mood changes 2 An increase in allergies 3 Strong food preferences Correct 4 Changes that occur with puberty It is appropriate for the nurse to provide anticipatory guidance related changes that occur with puberty for the parents of a 12-year-old school age client. Anticipatory guidance for a 7-year-old client should include an increase in allergies. Erratic mood changes and strong food preferences occur more often for the 6-, not 12-year-old client

5. Which result does the nurse anticipate when providing care to a preschool-age child who successfully completes tasks associated with this stage of Erikson's theory of psychosocial development?

1 Faith and optimism 2 Devotion and fidelity Correct 3 Direction and purpose 4 Self-control and willpower Successful resolution of initiative versus guilt, which happens between the ages of 3 and 6 according to Erikson, results in direction and purpose. Resolution of trust versus mistrust (birth to 1 year) results in faith and optimism. The resolution of identify versus role confusion (puberty) results in devotion and fidelity. The resolution of autonomy versus shame and doubt (1 to 3 years) leads to self-control and willpower.

The nurse teaches a mother about the dietary measures to be followed for her 5-month-old infant. During the follow-up visit, the nurse finds that the child has indigestion. Which action by the mother is responsible for this situation?

1 Feeding almond milk to the child 2 Feeding vegetable juice to the child 3 Feeding bottle milk at night to the child Correct 4 Feeding properly mashed sweet potatoes to the child The enzyme amylase is needed for the digestion of complex carbohydrates. A 4- to 6-month-old infant is deficient in amylase. Sweet potatoes are rich in complex carbohydrates; therefore the 5-month-old infant can have indigestion from eating sweet potatoes. Almond milk, vegetable juice, and bottle milk do not contain complex carbohydrates; therefore, they do not result in indigestion. STUDY TIP: Becoming a nursing student automatically increases stress levels because of the complexity of the information to be learned and applied and because of new constraints on time. One way to decrease stress associated with school is to become very organized so that assignment deadlines or tests do not come as sudden surprises. By following a consistent plan for studying and completing assignments, you can stay on top of requirements and thereby prevent added stress.

The nurse observes dental caries in an 8-month-old infant. Which action of the parents is likely responsible for this condition?

1 Giving the infant canned fruit Correct 2 Giving the infant fruit juice in a bottle 3 Giving the infant 960 mL of milk daily 4 Giving the infant cheese as a finger food Giving an infant fruit juice in a bottle can result in dental caries. Giving an infant canned fruits and vegetables can result in lead poisoning, not dental caries. Giving an 8-month-old infant 960 mL of milk is appropriate and does not result in dental caries. Cheese can be given as a finger food to an 8-month-old infant and may not result in dental caries. STUDY TIP: A word of warning: do not expect to achieve the maximum benefits of this review tool by cramming a few days before the examination. It doesn't work! Instead, organize planned study sessions in an environment that you find relaxing, free of stress, and supportive of the learning process.

A nursing instructor asks a nursing student about Kohlberg's theory. Which stages does a nurse include under the first level of the theory? Select all that apply.

1 Good boy-nice girl orientation 2 Society-maintaining orientation Correct 3 Instrument relativist orientation 4 Universal ethical principle orientation Correct 5 Punishment and obedience orientation The first level of Kohlberg's theory is preconventional reasoning, which includes the instrument relativist orientation stage and punishment and obedience orientation stage in the first level. Good boy-nice girl orientation stage and society-maintaining orientation stage are covered under the conventional reasoning level. Universal ethical principle orientation stage is a part of postconventional reasoning. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

What is the first action a nurse should take before administering a tube feeding to an infant?

1 Irrigating the tube with water Correct 2 Offering a pacifier to the infant 3 Slowly instilling 10 mL of formula 4 Placing the infant in the Trendelenburg position A pacifier should be given during the feeding to help the infant associate sucking with feeding and to meet oral needs. Irrigating the tube with water will cause complications if the tube is not in the stomach. Ten milliliters of formula should be instilled slowly after placement of the tube and verification of residual return. Upright positioning is essential to prevent regurgitation or reflux and subsequent aspiration. Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the "old" material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge of the topics. Start this review process on the first day of the semester. Don't wait until the middle to end of the semester to try to cram information.

A nurse assessing a newborn reports an asymmetric Moro reflex, and Erb palsy is diagnosed. What does the nurse understand about the origin of this problem?

1 It is acquired in utero. 2 It is a tumor arising from muscle tissue. 3 The cause is an X-linked inheritance pattern. Correct 4 The cause is an injury to the shoulder during birth. Erb palsy results from forces that alter the alignment of the arm, shoulder, and neck; stretching or pulling away of the shoulder from the head during birth damages the brachial plexus. Erb palsy is not acquired in utero and is not a tumor or an X-linked inherited disease. Test-Taking Tip: Avoid spending excessive time on any one question. Most questions can be answered in 1 to 2 minutes

A nurse is preparing for a teaching session with the parents of an infant with phenylketonuria (PKU). The parents are upset and want an explanation of why the child has this disease that they have never heard of. What should the nurse consider before responding?

1 It is contracted during the birth process. 2 It is a lifelong disorder of unknown origin. 3 This congenital disorder was caused by an intrauterine infection. Correct 4 This autosomal recessive disorder was inherited from parents who are carriers. PKU is an inherited metabolic disorder; the parents do not have the disorder (autosomal recessive) because two copies of the gene (one from each parent) are necessary for expression of the disorder. PKU is not contracted during birth or as an infection; it is inherited. The origin, pathophysiology, treatment, and outcomes are known.

A nurse is caring for a 6-day-old preterm infant in the neonatal intensive care unit. What complications should the nurse be alert for in this infant?

1 Meconium ileus 2 Duodenal atresia 3 Imperforate anus Correct 4 Necrotizing enterocolitis Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa that is related to several factors (e.g., prematurity, hypoxemia, high-solute feedings); it involves shunting of blood from the gastrointestinal tract, decreased secretion of mucus, greater permeability of the mucosa, and increased growth of gas-forming bacteria, eventually resulting in obstruction. NEC usually manifests 4 to 10 days after birth. Meconium ileus occurs within the first 24 hours when the newborn cannot pass any stool. It is not related to the development of NEC; it is a complication of cystic fibrosis. Duodenal atresia is a congenital defect that occurs early in gestation and is present at birth. Imperforate anus is an anorectal malformation that results in the absence of an external anal opening; it is present at birth.

What common finding can the nurse identify in most children with symptomatic cardiac malformations?

1 Mental retardation 2 Inherited genetic disorders Correct 3 Delayed physical growth 4 Clubbing of the fingertips Children with cardiac malformations often require more energy to fulfill the activities of daily living; decreased oxygen utilization and increased energy output in the developing child result in a slow growth rate. Mental retardation is not a common finding in children with congenital heart disease. Cardiac anomalies are more often a result of prenatal, rather than genetic, factors. Clubbing is not characteristic of most children with cardiac anomalies, only of those with more severe hypoxia

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?

1 Monitoring growth patterns and plotting on the growth chart 2 Teaching the client and family how the illness affects physical growth 3 Assessing stage of development frequently and documenting it in the medical record Correct 4 Planning activities to promote progression from one stage of development to the next The priority nursing action to facilitate growth and development when providing care to a pediatric client who is diagnosed with a chronic illness is to plan activities that will promote the progression of the client from one stage of development to the next. Chronic illness can often cause developmental delays. Monitoring growth patterns, plotting on the growth chart; educating the client and family about how the illness affects physical growth; assessing the stage of development and documenting in the medical record are all appropriate nursing actions; however, these are not the priority for facilitating growth and development for this client.

After surgery for a myelomeningocele, an infant is being fed by means of gavage. When checking placement of the feeding tube, the nurse is unable to hear the air injected because of noisy breath sounds. What should the nurse do next?

1 Notify the provider. 2 Advance the tube 1 cm. 3 Insert 1 mL of formula slowly. Correct 4 Try aspirating stomach contents. Gastric returns indicate correct placement of the feeding tube. Further assessment is necessary before the provider is notified. Advancing the tube even 1 cm may cause undue trauma, regardless of where the tube is located. Inserting even a small amount of formula is unsafe until correct placement is verified; formula may enter the lungs if the tube is not in the stomach.

The nurse is providing care to a school-age client who is overweight. Which nursing action is appropriate to enhance the client's intake of a healthy diet?

1 Offering food as a reward for good grades 2 Encouraging the consumption of high-fat foods 3 Educating on the importance of soda consumption Correct 4 Making fruits and vegetables available for daily snacks Making fruits and vegetables available for daily snacks is a nursing action that will enhance the overweight school-age client's intake of a healthy diet. Rewarding good grades with food should be avoided; instead the nurse would offer stickers. It is appropriate for the nurse to encourage the consumption of low-fat, not high-fat, foods. Soda is a source of empty calories; therefore, this action should be avoided.

A child watches an older sibling playing with a ball, but makes no effort to participate in the play. What social character of play is the child exhibiting?

1 Parallel play 2 Pretend play Correct 3 Onlooker play 4 Associative play In onlooker play a child actively observes other children playing and does not attempt to enter into the activity; the child is interested only in observation and not in participation. In parallel play children play independently among other children. In pretend play children act out any event of daily life and practice the roles and identities as established in their surroundings. In associative play children play together and are engaged in a similar or identical activity.

Which auditory test is appropriate for infants?

1 Play audiometry 2 Pure tone audiometry Correct 3 Behavioral audiometry Incorrect 4 Auditory brainstem response (ABR) Behavioral audiometry is used for infants. Play audiometry is used for toddlers. Pure tone audiometry is used for children and adolescents. ABR is used for newborns.

A nurse is caring for an infant after a cleft lip repair. Which item should the nurse use to feed the infant for several days after the surgery?

1 Preemie nipple 2 Nasogastric tube 3 Gravity-flow nipple Correct 4 Rubber-tipped syringe A rubber-tipped syringe minimizes sucking and is not irritating to the suture line. Using a preemie nipple is one method of feeding before surgery. A nasogastric tube is unnecessary; the infant is hungry enough to feed even if deprived of sucking. Using a gravity-flow nipple is one method of feeding before surgery.

The mother of an infant with a congenital heart defect who was admitted to the pediatric unit with heart failure asks why her baby must be weighed each morning. The nurse explains that the baby's treatment is based on changes in the daily weight. What complication can be prevented if treatment is successful?

1 Renal failure Correct 2 Fluid retention 3 Digitalis toxicity 4 Protein malnutrition Fluid retention is reflected by an excessive weight gain in a short period of time; inadequate cardiac output decreases blood flow to the kidneys, which leads to increased intracellular fluid and hypervolemia. Daily weights are appropriate if renal disease or hypovolemia is present; however, other assessments such as hourly urine output, blood urea nitrogen, and creatinine values provide a more accurate assessment of kidney function. Weight is helpful in determining medication dosages, but daily weights are not used to diagnose digitalis toxicity. Weight gain or loss resulting from nutritional intake is gradual and will not vary on a day-to-day basis.

A nurse is discussing an infant's diet with a mother who is breastfeeding. Why should the nurse recommend that the infant be offered solid foods by 5 or 6 months of age? Select all that apply.

1 Solid foods help control weight. Correct 2 Fetal iron reserves are depleted. Correct 3 Food can be taken from a spoon. 4 Bone marrow activity has diminished. 5 Breast milk lacks nutrients after 5 months. Fetal iron reserves are depleted by the fifth to sixth month. Although breast milk or formula is the major form of nutrition during the second half of the first year, exogenous iron should be introduced in the form of foods, such as iron-fortified cereal. Exogenous iron prevents iron-deficiency anemia. Formula-fed infants can receive iron in iron-fortified formula and may be offered foods later in the first year. Because the extrusion reflex has disappeared by this age, breastfed infants should be offered foods that contain iron. Although overingestion of milk can cause weight gain, so can overingestion of solid food. It is not the bone marrow production of cells but the decreased production of hemoglobin that can cause iron-deficiency anemia. Breast milk still provides adequate nutrients. The American Academy of Pediatrics (Canada: Public Health Agency of Canada) recommends continuation of breastfeeding until at least 12 months of age.

A nurse is caring for a 4-week-old infant with hypertrophic pyloric stenosis who has been admitted to the pediatric unit for corrective surgery. What is the primary objective of preoperative care for this infant?

1 Stabilizing vital signs 2 Improving nutritional status Correct 3 Correcting fluid and electrolyte imbalances 4 Documenting the amount and character of vomitus Preoperative restoration of fluid and electrolyte balance improves the likelihood of a successful outcome after surgery. Vital signs are stabilized as the fluid and electrolyte balances are corrected. Improving nutritional status is not a preoperative objective; the nutritional status should improve after surgery. The amount and character of vomitus are important, but neither is the primary objective of preoperative nursing care.

A 3-year-old child feels a sense of rivalry with his father and wants him to die. Shortly after these feelings emerge, the child's father dies in a road accident. The child then begins to feel intense guilt, believing that he caused the death. What is the best nursing intervention in this situation?

1 Teach relaxation techniques to the child. 2 Encourage the child to play with his siblings. 3 Suggest that the child's uncle spend time with him. Correct 4 Explain to the child that wishes do not make things happen. The nurse should clarify the child's thoughts and help reduce feelings of guilt by explaining that wishes do not make events occur. Relaxation techniques help to reduce anxiety but do not reduce the feeling of guilt. Playing with siblings or spending time with an uncle may help relieve the child's stress, but they do not address the feelings of guilt. Test-Taking Tip: Look for answers that focus on the client or are directed toward feelings.

A nurse is planning to assess the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?

1 The bile duct is obstructed by the pyloric sphincter. Correct 2 There is an obstruction above the opening of the common bile duct. 3 The bile duct sphincter is connected to the hypertrophied pyloric muscle. 4 There is a constriction of the cardiac sphincter that obstructs the flow of bile. The common bile duct enters the duodenum. The pyloric sphincter is located between the end of the stomach and the beginning of the duodenum; therefore when it is hypertrophied the tight sphincter prevents any mixing of vomited formula with bile. Pyloric stenosis involves hypertrophy and hyperplasia of the muscle of the pyloric sphincter; the bile duct is intact. The bile duct enters the duodenum at a site different from the pyloric sphincter and is uninvolved in pyloric stenosis. The area affected in pyloric stenosis is the pyloric sphincter (which is between the stomach and duodenum), not the cardiac sphincter (which is between the stomach and esophagus). Test-Taking Tip: Make educated guesses when necessary.

The nurse is assessing a newborn whose parents are Asian. The nurse finds that the child has irregular, deep-blue pigmentation on the gluteal regions. What does the nurse interpret from these findings?

1 The child has milia. Correct 2 The child has Mongolian spots. 3 The child has erythema toxicum. 4 The child has harlequin color change. Mongolian spots are a medical condition characterized by the appearance of irregular, deep-blue pigmented spots on the gluteal regions. This skin abnormality is a common finding in newborns of Asian descent. Milia are distended sebaceous glands, which manifest as tiny white papules on cheeks, chin, and nose. Erythema toxicum manifests as a pink papular rash on the thorax, back, and buttocks. Harlequin color change is a clear line through the body caused by lying on one side. The side on which the baby sleeps turns pink.

An infant with the diagnosis of exstrophy of the bladder undergoes surgery to close the defect. What must the nurse include in the discharge teaching for the parents?

1 The need for a tub bath after each defecation Correct 2 How to identify signs of a urinary tract infection 3 The need for rubber pants to contain urinary drainage 4 How to maintain the supine position to decrease urine drainage Urinary tract infections are a major concern and must be treated early. Rubber pants promote infection because they hold moisture close to the body; a warm, moist environment promotes the growth of pathogens. Sponge baths are given to prevent infection from bathwater. The amount of urine produced or excreted is not affected by positioning.

While performing a physical examination on an 11-year-old girl, the nurse examines the client's chest, and notes that all findings are normal. Which is the most likely observation that the nurse has made?

1 The sternum protrudes outward. Incorrect 2 The respiratory movement is principally diaphragmatic. Correct 3 The abdomen falls when the chest falls during respiration. 4 The anteroposterior diameter of the chest equals the lateral diameter. The chest and the abdomen should always rise and fall together regardless of the child's age and type of respiratory movement. This denotes a normal finding. A sternum that protrudes outward indicates pigeon chest, which is an example of altered chest shape. In children younger than 6 or 7 years, respiratory movement is principally abdominal or diaphragmatic. In older children, particularly girls, respirations are chiefly thoracic. During infancy the chest's shape is almost circular, with the anteroposterior diameter equaling the transverse, or lateral (side-to-side), diameter. As the child grows, the chest normally increases in the transverse direction, causing the anteroposterior diameter to be less than the lateral diameter. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A nurse is assessing an infant for developmental dysplasia of the hip. How does the nurse identify the Ortolani sign? sign.

1 Unilateral droop of the hip 2 Broadening of the perineum 3 Apparent shortening of one leg Correct 4 Audible click on hip manipulation With specific manipulation an audible click may be heard as the femoral head slips into the acetabulum; this is known as the Ortolani sign. Unilateral droop of the hip is the Trendelenburg sign; it is associated with weight bearing. Broadening of the perineum is associated with bilateral dislocation. Apparent shortening of one leg is the Allis

Which should the nurse encourage for the adolescent client diagnosed with a chronic illness to achieve independence from family?

1 Using coping skills 2 Wearing make-up 3 Buying stylish clothes Correct 4 Socializing with peers Socialization with peers should be encouraged [1] [2] for adolescent clients diagnosed with a chronic illness to achieve independence from family. Use of coping skills helps the adolescent develop a personal identity. Wearing make-up and buying stylish clothes allows the adolescent to learn through abstract thinking

An 11-month-old is admitted with dehydration and a serum sodium level of 120 mEq/L (120 mmol/L). Reporting of which assessment finding to the healthcare provider is a priority?

1 Weight loss of 1.5 kg in 3 days Correct 2 Muscle twitching in all extremities 3 Temperature increase to 100° F (37.8° C) 4 Heart rate increasing from 100 to 120 beats/min The normal sodium level is 135 to 145 mEq/L (135 to 145 mmol/L). A priority symptom of hyponatremia (less than 135 mEq/L (135 mmol/L)) is seizure activity, which may manifest early on as muscle twitching. Although a client may exhibit an increase in temperature or heart rate or a loss of weight as a result of dehydration, none of these is the priority assessment finding.

A nurse is planning an initial home care visit to a mother who has given birth to a high-risk infant. At what time of day should the nurse schedule the visit for it to be most productive?

1 When the husband is out of the home 2 At a time when the mother is feeding the infant Correct 3 At a time that will be convenient for the family 4 When the nurse can spend time with the family The family members are more inclined to share problems with the nurse if they are not feeling pressured; in addition, a visit that is convenient to the family helps foster a productive relationship. The father should be included in the visit if at all possible. Visiting while the mother is feeding the infant may be inconvenient for the mother and interfere with her productivity. A time when the nurse is able to spend time with the family may also be a time that is inconvenient for the family and therefore likely to interfere with productive interaction.

A nurse is caring for an infant with severe dehydration. Which blood gas report most likely reflects the acid-base balance of this infant?

1 pH of 7.50 and Pco 2 of 34 mm Hg Incorrect 2 pH of 7.23 and Pco 2 of 70 mm Hg Correct 3 pH of 7.20 and HCO 3 - of 20 mEq/L (20 mmol/L) 4 pH of 7.56 and HCO 3 - of 30 mEq/L (30 mmol/L) Low blood pH and bicarbonate levels indicate metabolic acidosis, which occurs with severe dehydration because the reduced urine output causes retention of hydrogen ions. The other options include findings that indicate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis, respectively.

3. If hearing loss is detected early, proper intervention can help a child achieve normal language development. What is the latest age that hearing loss should be detected to ensure that a child achieves normal language development? Record your answer using a whole number. ______________ months

3 If a healthcare provider detects hearing loss before the child is three months old and an intervention is initiated within six months, the child can achieve normal language development.

How many teeth does a 10-month-old infant usually have? Record your answer using a whole number. ____________ According to a quick guide to assessment of deciduous teeth, the number of teeth in a child during the first 2 years is calculated using the formula [Age of the child in months] - 6 = [Number of teeth]. The age of child is 10 months; therefore, the number of teeth is 10 - 6 = 4 teeth.

4

The nurse observes that there is plaque on the child's teeth. There are also signs of simple gum inflammation. Which condition does the nurse suspect in the child?

Correct 1 Gingivitis 2 Dental injury 3 Malocclusion 4 Periodontitis Plaque and gum inflammation indicates gingivitis. Dental injury may be seen if there is chipping or dislocation of the teeth. Malocclusion refers to uneven, crowded, or overlapping teeth, such that the upper and lower dental arches do not approximate properly. Periodontitis is an inflammation of the gums and a loss of connective tissue and bone in the supporting structures of the teeth.

What assessment finding in a newborn is suggestive of cystic fibrosis? 1

Rapid heart rate 2 Excessive crying Incorrect 3 Sternal retractions Correct 4 Abdominal distention Meconium ileus is an indication that a newborn may have cystic fibrosis. The small intestine is blocked with thick, tenacious, mucilaginous meconium, usually near the ileocecal valve. This causes intestinal obstruction with abdominal distention, vomiting, and fluid and electrolyte imbalance. Rapid heart rate is not a sign of cystic fibrosis in the newborn. Excessive crying does not have special significance in cystic fibrosis. Sternal retractions are not a sign of cystic fibrosis in the newborn. Test-Taking Tip: Relax during the last hour before an exam. Your brain needs some recovery time to function effectively.

The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates the need for further teaching?

1 "I can try foods of different tastes for my child." Correct 2 "I can leave my child with my new friend for some time." 3 "I should encourage my child to play peek-a-boo games." 4 "I should buy a toothbrush with soft bristles for my child." The fear of strangers increases in infants by 7 months of age. Therefore, the mother should not leave the infant with new people. The 7-month-old infant has taste preferences; therefore, the mother can try foods with different tastes for the child. The 7-month-old infant enjoys peak-a-boo games; therefore, the mother can play this game with the child. The 7-month-old infant has eruption of the upper central teeth; therefore, the mother can buy a toothbrush with soft bristles for the child to maintain oral hygiene. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.

Upon interacting with the parent of an 8-month-old infant, the nurse anticipates that the infant is at risk of childhood obesity. Which statement from the parent supports the nurse's assumption?

1 "I often feed my child cereal." 2 "I often feed my child oatmeal." Correct 3 "I often give my child potato chips." 4 "I feed my child mashed ripe banana." Foods like potato chips, candy, ice cream, cake, soda pop, and other sweetened drinks increase cholesterol levels and result in obesity. High-protein cereals do not increase cholesterol levels in the body, and do not contribute to childhood obesity. Mashed ripened banana does not increase cholesterol levels in the body and does not contribute to childhood obesity. Oatmeal reduces the risk of obesity in the child. Test-Taking Tip: You have at least a 25% chance of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond?

1 "The neurological lesions changed as your baby matured." 2 "Joint deformities don't appear until after 6 months of age." 3 "The staff members didn't want to alarm you until it was necessary." Correct 4 "Until there's control of voluntary movement, a diagnosis can't be confirmed." Cortical control of voluntary muscles occurs between 2 and 4 months of age. The neurological lesions are fixed and will neither progress nor regress. Cerebral palsy is not diagnosed on the basis of the presence of joint deformities; these may develop later because of spastic muscle imbalance. Parents have a right to be informed of their child's diagnosis as soon as possible.

Which should the nurse anticipate, according to Erikson, when assessing a preschool-age child?

1 Being engaged in tasks 2 Questioning sexual identity Correct 3 Having highly imaginative thoughts 4 Wanting to participate in organized activities The nurse would anticipate that a preschool-age child would have highly imaginative thoughts [1] [2], according to Erikson. Being engaged in tasks and wanting to participate in organized activities is expected for the school-age child. Questioning sexual identity is expected for the adolescent.

During the assessment of a hospitalized infant, the nurse notes dry mucous membranes, absence of tears when the infant cries, and poor skin turgor. Which parameter will help the nurse further evaluate these findings?

1 Daily serum electrolytes 2 Respiratory rate and rhythm Correct 3 Intake and output over the past 24 hours 4 Alterations in heart sounds since admission The infant is exhibiting signs of severe dehydration. The monitoring parameter that will be most helpful for evaluating these findings is intake and output, because checking this will help the nurse determine whether intake is adequate or fluid loss is excessive. Serum electrolytes, respiratory rate and rhythm changes, and certain changes in heart sounds are more likely to be the result of, rather than cause of, dehydration. Deteriorating cardiac function is more likely to lead to fluid retention than to fluid loss or dehydration. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

A nurse is caring for an infant with phenylketonuria. What diet should the nurse anticipate will be prescribed by the healthcare provider?

1 Fat-free 2 Protein-enriched 3 Phenylalanine-free Correct 4 Low-phenylalanine Because phenylalanine is an essential amino acid, it must be provided in quantities sufficient for the promotion of growth but low enough to maintain a safe blood level. Phenylalanine is derived from protein, not fat. An enriched-protein diet contains increased amount of proteins, including phenylalanine, which should be ingested in limited amounts. Because phenylalanine is an essential amino acid, it cannot be totally removed from the diet. Test-Taking Tip: Note the number of questions and the total time allotted for the test to calculate the times at which you should be halfway and three-quarters finished with the test. Look at the clock only every 10 minutes or so.

An infant who was just returned to the pediatric unit after surgery is drowsy. What should the nurse do to maintain an airway? .

1 Have a tongue blade available. 2 Use nasotracheal suction routinely. 3 Keep the child in the supine position. Correct 4 Place the child in a side-lying position. The side-lying position will allow emesis or other obstructive fluid to drain from the mouth and prevent aspiration. Tongue blade insertion will not prevent aspiration. Nasotracheal suction used routinely will traumatize the posterior pharynx and trachea; suctioning should be performed only if necessary. The supine position predisposes the child to aspiration of blood, mucus, or vomitus

If a 5½-month-old infant's immunizations are on schedule, which immunizations does the nurse expect the infant to have had already?

1 Measles, mumps, and rubella vaccine 2 Booster dose of inactivated polio vaccine Correct 3 Two doses of diphtheria, tetanus, and pertussis vaccine 4 First booster dose of diphtheria, tetanus, and pertussis vaccine The schedule for active immunization is three doses of diphtheria, tetanus, and pertussis (DTaP) at 2-month intervals beginning at 2 months of age. The measles, mumps, and rubella vaccine is not given until 12 to 15 months because maternal antibodies block the formation of the infant's antibodies. An inactivated polio vaccine booster (fourth dose) is due at 4 to 6 years of age. The first booster dose of DTaP is given at 15 to 18 months, or approximately 1 year after the third dose that is given at 6 months of age.

A nurse is performing a neurologic assessment of a 7-month-old infant. What reflex should the nurse be able to elicit?

1 Moro Correct 2 Babinski 3 Tonic neck 4 Palmar grasp The Babinski reflex remains evident throughout the first 12 months of life. The Moro or startle reflex disappears by 4 months of age. The tonic-neck reflex disappears by 4 months of age. The palmar grasp reflex lessens at 3 months and is replaced by the voluntary pincer grasp by 8 months.

An infant is admitted to the intensive care unit with multiple injuries. When the adolescent mother sees her infant for the first time, she cries out, "I didn't mean to hurt her!" What should the nurse do first?

1 Notify child protective services. 2 Encourage the mother's family to visit and comfort her. Correct 3 Offer support by saying, "This must be difficult for you." 4 Respond by saying, "You caused your baby's injury, and you feel guilty." This response is accepting of the individual and encourages further communication to clarify the meaning of the mother's statement. There are no data in the question to indicate that the injuries were caused by abuse. The mother's statement requires further clarification before child protective authorities are notified. Encouraging the mother's family to visit is not the first action for the nurse. Guilt may or may not be the true interpretation of the client's statement

An infant with a congenital heart defect is returned to the unit after cardiac catheterization. The nurse manager is observing a nurse newly assigned to the unit. Which nursing intervention should the nurse manager interrupt?

1 Offering fluids and foods as tolerated Correct 2 Performing range-of-motion exercises 3 Monitoring the apical pulse for rate and rhythm 4 Assessing the pulses distal to the catheterization site Range-of-motion exercises of the limb bearing the catheterization site might cause the dislodgement of a clot and result in hemorrhage. Intake should start with fluids and progress as tolerated. The apical pulse is monitored because a common complication after cardiac catheterization involves disturbances of cardiac rate and rhythm. The peripheral pulses are assessed because formation of thrombi is a complication of cardiac catheterization.

A nurse is caring for a child with chordee. The parents ask why corrective surgery is necessary. Before responding, the nurse considers that if a chordee is not surgically corrected, the child will be at increased risk for what when reaching adulthood?

1 Renal failure 2 Testicular cancer 3 Testicular torsion Correct 4 Sexual dysfunction The presence of uncorrected chordee can affect a child's future sexual capabilities, because the condition will make sexual penetration impossible. Kidney function is not affected. The incidence of testicular cancer is not increased; nor is the risk of testicular torsion.

In which stage of Kohlberg's theory of moral development does the nurse anticipate a client to realize there is more than one right point of view?

1 Stage 1 Correct 2 Stage 2 3 Stage 3 Incorrect 4 Stage 4 Level I, preconventional reasoning, stage 2, is when the nurse anticipates that the client will realize there is more than one right view. In level I, stage 1, the nurse would anticipate absolute obedience to authority and rules. In level II, conventional reasoning, stage 3, the child wants to win approval and maintain expectations of his or her immediate group. Level II, stage 4, is when the client expands focus from the relationship with others to societal concerns

Which stage describes the Oedipus complex, according to Freud's theory?

1 Stage 2 Correct 2 Stage 3 3 Stage 4 4 Stage 5 According to Freud's theory, there are five stages in a child's development. Stage 3 is the Oedipal stage, which is also known as the phallic stage. Stage 2 is the anal stage. Stage 4 is the latency stage. Stage 5 is the genital stage.

An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer solution intravenously. The nurse concludes that the treatment has been effective after noting what?

1 Tenting turgor 2 Pink mucous membranes Correct 3 Three wet diapers in 24 hours 4 Capillary refill longer than 2 seconds Three or more wet diapers in 24 hours indicates that fluid balance is improving and that the kidneys are functioning. Tenting turgor, fewer than three wet diapers in a day, and capillary refill of more than 2 seconds are all signs of dehydration, not of improvement

Which data collected during the nursing assessment for a 24-month-old client indicates the need for further evaluation for delayed language? Select all that apply.

1 The child uses two-word sentences. Correct 2 The child cries and points at an object he wants. 3 The child states, "Me do it" when asked to stack blocks. Correct 4 The child understands the meaning of as many as 50 words. 5 The child asks, "What's that?" when the nurse uses the stethoscope to assess lung sounds. Observations made during the nursing assessment for a 24-month-old client that would require further evaluation for a language delay include: the child crying and pointing at an object that is wanted and the child who understands the meaning of only 50 words (300 is expected by this stage of development). The use of two-word sentences, "Me do it," and asking "What's that?" are all expected findings for the 24-month-old client in regards to language development.

The parents of a preschooler inform the nurse that their child often develops diarrhea and ask whether there might be anything wrong with the child's stomach. Upon assessment, the nurse also finds that the child has poor oral care and is at risk for dental caries. What is the most probable cause for the child's health issues?

1 The family often consumes fast foods. 2 The parents neglect the child's dietary needs. 3 The family does not follow hygienic practices. Correct 4 The child consumes excessive amounts of fruit juice. If the child consumes excessive fruit juice or sweetened beverages, it increases the risk for dental caries and gastrointestinal conditions, such as chronic diarrhea. Consuming fast foods often result in childhood obesity, because fast foods are high in fats and starches. Neglecting the dietary needs or not following hygienic practices may cause gastrointestinal problems or make the child susceptible to infections.

While assessing a neonate who was born at 42 weeks of gestation via vaginal delivery, the nurse finds that the neonate has a birth weight of 9 lb (4.1 kg). The nurse also assesses for Moro reflex and focal swelling or tenderness in the neonate. Why does the nurse perform these interventions?

1 To evaluate for facial paralysis Correct 2 To evaluate for clavicle fracture 3 To evaluate for ophthalmia neonatorum 4 To evaluate for erythema toxicum neonatorum Birth at a postterm gestational age via vaginal delivery with a birth weight of more than 8.5 lb (3.8 kg) are risk factors associated with fracture of the clavicle during labor. A neonate with a fractured clavicle will show an asymmetric Moro reflex and focal swelling or tenderness. Facial paralysis does not result from normal vaginal delivery or late gestational age and is not characterized by asymmetric Moro reflex. The nurse assesses the neonate's eyes to evaluate for ophthalmia neonatorum but not Moro reflex. The nurse assesses for skin integrity and white to yellowish papules on the skin associated with erythema toxicum neonatorum

Which nursing action promotes psychosocial development for a newborn?

1 Washing hands prior to holding the newborn 2 Measuring the newborn using an approved length board 3 Weighing the newborn on the same scale during hospitalization Correct 4 Placing the newborn in the mother's arms during the first hour of life Placing a newborn in the mother's arms for the first hour of life is a nursing action that promotes psychosocial development, in the form of bonding with his or her mother. Washing hands prior to holding the newborn is hospital policy and promotes infection prevention and control. Measuring the newborn's length using an approved length board and weighing the newborn on the same scale each day during hospitalization allows the nurse to assess newborn growth.

A worried parent informs the nurse, "My 6-year-old is otherwise healthy but still wets the bed at night." The nurse is teaching the parent necessary steps to manage the child's nocturnal enuresis. Which statement made by the parent indicates effective learning? Select all that apply.

Correct 1 "I should avoid giving my child fruit juice after 4:00 pm." Correct 2 "I should encourage my child to drink lots of water during the day." 3 "I should make my child wear diapers during day hours while at school." 4 "I should give my child diet soda instead of regular soda in the evening." Correct 5 "I should wake my child at the same time every night to use the bathroom." Proper bladder control develops at the age of 2 to 3 years. However, this child is 6 years old and wets the bed at night, which indicates that the child has nocturnal enuresis. Fruit juice is high in water content; therefore, the nurse instructs the parents to avoid giving the child fruit juice after 4:00 pm to help prevent the child urinating during the night. To compensate for lower fluid intake in the evening, the parents should encourage the child to drink water during the day. Setting a routine by predetermining the time to urinate at night will reduce the risk of enuresis. The parents should not embarrass the child by making him or her wear diapers. Normal pajamas should be used instead of diapers. Diet soda is a carbonated beverage, which increases urination. Therefore, the nurse instructs the parents to avoid carbonated beverages after 4:00 pm. Test-Taking Tip: Be alert for details about what you are being asked to do. In this Question Type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate directly to the situation.

The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers?

Correct 1 "This growth pattern is typical at this age." 2 "Toddlers are too busy exploring their world to eat." 3 "This growth pattern can't be interpreted for another year." 4 "Toddlers usually lose their taste for foods they liked when younger." As the child gets older, growth slows. Toddlers develop physiologic anorexia because their appetite decreases along with their growth rate. Although the toddler may be too busy to eat, this is not why the growth rate slows. This growth pattern may be interpreted now. Although a toddler may lose his or her taste for a particular food, it is not common in this age group. STUDY TIP: Record the information you find to be most difficult to remember on 3" × 5" cards and carry them with you in your pocket or purse. When you are waiting in traffic or for an appointment, just pull out the cards and review again. This "found" time may add points to your test scores that you have lost in the past.

Which assessment question is appropriate when collecting a developmental history for an adolescent who is new to the pediatric practice?

Correct 1 "What grades do you get in school?" 2 "Have your wisdom teeth erupted yet?" 3 "What was your approximate height at 4 years of age?" 4 "What was your approximate weight at 5 years of age?" While all of these assessment questions are appropriate, only the question regarding scholastic performance (grades in school) is a question that is appropriate for a developmental history. Asking questions regarding wisdom tooth eruption and approximate height and weight at 4 and 5 years of age respectively is more appropriate when collecting a growth histor

A nurse is obtaining a health history from the mother of a 2-month-old infant with a diagnosis of hypertrophic pyloric stenosis (HPS). What is the most significant finding about the cause of the infant's HPS?

Correct 1 A first cousin underwent surgery for HPS. 2 The birth was preterm, and the birth weight was 4 lb (1814 g). 3 An older brother had idiopathic vomiting during infancy. Incorrect 4 The older sister experienced an intestinal obstruction during early infancy. The higher incidence of HPS among first-degree relatives seems to indicate a hereditary cause. Full-term infants are more likely to be affected than preterm infants. HPS is not related to other gastrointestinal disorders, even among close relatives.

During a clinical assessment, what secondary sex characteristics does the nurse observe in a teenage client? Select all that apply.

Correct 1 Change in voice Incorrect 2 Enlargement of breasts Correct 3 Development of facial hair Incorrect 4 Beginning of menstruation 5 Completion of skeletal growth Secondary sex characteristics are the changes observed in various parts of the body from hormonal alterations. Voice change occurs as a result of changes in the larynx, and facial hair develops on the face and neck regions. Primary sex characteristics are the changes that occur in the internal and external organs involved in reproductive functions. Enlargement of breasts and beginning of menstruation are regarded as primary sex characteristics. The completion of skeletal growth is seen in postpubescence and is not a secondary sex characteristic. Test-Taking Tip: Be alert for details. Details provided in the stem of the item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). How often does the nurse tell the parents to bring their baby back to the clinic for a cast change?

Correct 1 Each week 2 Once a month 3 When the cast edges fray 4 If the cast becomes soiled Casts are changed weekly to accommodate the rapid growth of early infancy. Once a month is not frequent enough in early infancy; the cast may become too tight because of the infant's rapid growth. The cast is not on the foot long enough for fraying to occur. Soiling is usually not a problem, because casts for clubfoot do not extend to the perineal area.

The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. The nurse responds that it usually occurs during fetal development during what time?

Correct 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase The critical period of organogenesis occurs during the first trimester, when fetal development is most likely to be adversely affected. The fetus is less vulnerable after the first trimester because organ development is complete. The fetus is less vulnerable to major anomalies during the second 16 weeks because all major organ systems already are formed. At the time of implantation cellular differentiation has not occurred; the genital bud appears in the seventh week.

A nurse is selecting toys for a 5-month-old infant. Which toy should not be given to the infant?

Correct 1 Large snap beads 2 Soft stuffed animals 3 Rattles that can be held 4 Brightly colored mobiles Fine motor coordination is developed inadequately for manipulation of snap toys. Soft stuffed animals stimulate the sense of touch, and because voluntary grasp appears at about 3 to 4 months, they can be handled satisfactorily. The voluntary grasp will allow the child to hold a rattle, and the rattling sound will stimulate the auditory system. Bright mobiles are appropriate to stimulate visual attention.

Which fine motor skill should the nurse expect when assessing the development of an infant between 10 and 12 months of age?

Correct 1 Holds a crayon 2 Walks with assistance 3 Stands independently 4 Sits from a standing position The ability to hold a crayon is a fine motor skill that the nurse should expect when conducting a developmental assessment for an infant between 10 to 12 months of age. Walking with assistance, standing alone, and sitting from a standing position are all gross motor skills the nurse would anticipate for this infant.

A nurse is assessing the oral cavity of a 6-month-old infant. The parent asks which teeth will erupt first. What is the nurse's response?

Correct 1 Incisors 2 Canines 3 Upper molars 4 Lower molars The bottom incisors are the first teeth to erupt, between 6 and 8 months of age. The canine teeth appear around 18 months. The first molars, both upper and lower, appear around 20 months.

An infant who has undergone surgery for hypertrophic pyloric stenosis (HPS) is being bottle fed by the mother. What should the nurse teach the mother about feedings to decrease the chance of the infant vomiting?

Correct 1 Start with small, frequent feedings. 2 Rock for 20 minutes after a feeding. 3 Keep the infant awake for 30 minutes after feeding. 4 Position the infant flat on the right side during feedings. Starting with small feedings will decrease the risk of vomiting. Rocking, keeping the infant awake, and positioning the infant horizontally all increase the chance of vomiting.

The mother of an infant with hypertrophic pyloric stenosis (HPS) asks the nurse many questions about the problem. What information should the nurse convey when answering these questions?

Correct 1 Surgery is usually necessary. 2 Chromosomal mutation is the cause. 3 Slow feeding will be required for several months. 4 Dietary restrictions must be maintained throughout childhood. Surgery is the treatment of choice for HPS. After surgery the infant usually has a rapid recovery with an excellent prognosis. HPS is not caused by a chromosomal mutation; it is a structural defect in which hypertrophy of the circular muscle of the pylorus causes obstruction at the pyloric sphincter. The infant will be tolerating regular feedings within 24 hours of surgery. A special diet is not required once fluids are tolerated.

The parents of an infant who has undergone surgical repair of a myelomeningocele express concern about skin care and ask what they can do to prevent problems. What should the nurse teach the parents about their infant's skin care?

Correct 1 Will require long-term multidisciplinary follow-up care 2 Should take prophylactic antibiotic therapy indefinitely 3 Must be kept dry by applying powder after each diaper change 4 Does not need anything more than routine cleansing and diaper changes These infants need follow-up care with a variety of healthcare providers (e.g., neurologist, physical therapist) to manage the child's condition during growth and development. Taking prophylactic antibiotic therapy indefinitely is unnecessary. Powder should be avoided; it will create a pastelike substance when mixed with urine, and when aerosolized it is a respiratory irritant. These children require more frequent perineal care than just routine cleansing and diaper changes.

Which school-age developmental characteristics increases the client's risk for poisoning? Select all that apply.

Incorrect 1 Trying new things Correct 2 Adhering to group rules Incorrect 3 Increasing independence Correct 4 Being easily influenced by peers Correct 5 Having a strong allegiance to friends Developmental characteristics of the school-age client that increase the risk for poisoning include adhering to group rule, being easily influenced by peers, and having a strong allegiance to friends. Trying new things and increasing independence increase the risk for burn injury, not the risk for poisoning.

One minute after birth a neonate's heart rate is 106 beats/min; acrocyanosis and muscle tone with flexion are observed; flicking the sole triggers crying, and the cry is strong. What is the neonate's Apgar score? The Apgar score is calculated from scores in five areas: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each area is given a score of 0, 1, or 2. Pulse over 100 = 2 points; good cry = 2 points; good muscle tone = 2 points; excellent reflex irritability (stimulus precipitates a cry) = 2 points; bluish extremities (acrocyanosis) = 1 point.

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