Family Exam 3

Immediately after childbirth in the recovery area, the nurse observes the mother's partner's fascination and interest in the new child. This behavior is often termed a. attachment b. engrossment c. bonding d. temperament

The correct response to the question is B because partner's or significant others' developing bond with the newborn—a time of intense absorption, preoccupation, and interest—is called engrossment. Responses A, C, and D are incorrect since they are terms typically describing the close relationship between the mother--infant dyad, not the father.

A 2-year-old has been prescribed eye patching for strabismus 6 hr/day. What teaching does the nurse provide for the mother? a. try to patch 6 hr/day, but if you miss some, it is ok b. patching is necessary to strengthen vision in the weaker eye c. patching will keep the eye from turning in d. since the child is so young, patching can be delayed until school-age

The correct response is c. It is very important to protect the operative site after any eye surgery. Elbow restraints prevent the infant from rubbing the eyes.

The nurse is caring for an infant who has undergone surgery for infantile glaucoma. What is the priority nursing intervention? a. place the child prone postoperatively for comfort b. teach the family use of the contact lens c. place elbow restraints on the infant d. provide a mobile for optical stimulation

The correct response is c. It is very important to protect the operative site after any eye surgery. Elbow restraints prevent the infant from rubbing the eyes.

A 4-year-old complains of extreme pain when the tragus is touched. Though not diagnostic, this sign is most indicative of which disorder? a. acute otitis media b. acute tympanic effusion c. otitis interna d. otitis externa

The correct response is d. Otitis externa, infection and inflammation of the ear canal, results in significant pain, particularly if the tragus is touched.

A new mother gave birth 12 hours ago. Because this is her first child, which goal planned by the nurse is most appropriate? a. early discharge for the mother and newborn b. rapid transition into the role of being a caregiver/parent c. minimal need for expression of feelings now d. effective education of both parents before discharge

The correct response to this question is D because both parents will need education about the newborn, how to care for it, and how to care for themselves.

The nurse is visiting with a 4 week postpartum client. What statements would cause concern to the nurse for the client's psychosocial wellbeing? SATA a. the client refers to herself as ugly or useless b. the client expresses that her support system has diminished greatly c. the client's appetite has increased d. the client is unable to discuss her labor or birth experience e. the client refuses to interact with the baby

a, b, d, e

The nurse is looking for signs of effective breastfeeding in the mother, which signs below would the nurse document as effective? (SATA) a. onset of copious milk production b. uterine contractions and increased vaginal bleeding while feeding c. decreased thirst in the mother d. breasts soften or feel lighter while feeding e. infant latches without difficulty f. infant has burst of 4-6 sucks/swallow at a time g. infant easily releases breast at the end of the feeding

a, b, d, e, g

The nurse is caring for an infant with myelomeningocele prior to having repair surgery. What nursing intervention(s) is necessary to include in this infant's plan of care? Select all that apply. a. Positioning of paralyzed legs to prevent contractures b. Keep the skin clean and dry c. Provide a pacifier for nonnutritive sucking d. Protect knees and elbows from skin breakdown e. Use a high-calorie, concentrated formula for feeds

a, b, d. Rationale:A myelomeningocele is a spinal cord defect. The sac protrudes through the skin. The spinal cord ends at the level of the defect causing no motor or sensory function below that point. The infant must remain in a prone position to keep from causing damage to the sac until repair can be done. This also means no diapers. Skin integrity and positioning are essential. This infant could have breakdown on the knees and elbows and even the side of the head. The infant needs to be cleaned regularly and kept dry. Different types of mattresses can be used to reduce pressure on bony prominences. The paralyzed lower extremities need to be repositioned regularly to prevent contractures. A high-calorie, concentrated formula is not necessary. Regular-calorie formula is adequate. A pacifier for nonnutritive sucking is a good idea and may be a comfort to the infant but it is not essential.

Nephrotic syndrome characteristics: a. oliguria b. dark, frothy urine c. generalized edema d. cola or tea-colored urine e. facial edema f. recent diarrhea g. post-streptococcal infection

A, B, E. Rat: edema is to LE and genitalia

Glomerulonephritis characteristics a. oliguria b. dark, frothy urine c. generalized edema d. cola or tea-colored urine e. facial edema f. recent diarrhea g. post-streptococcal infection

A, D, E, G. Rat: edema starts in face and goes to extremities and abdomen during day

Hirschsprung's characteristics: a. foul-smelling, ribbon-like stools b. sausage shaped abdominal mass c. constant hunger d. failure to pass meconium within 48 hours after birth e. sudden, episodic abdominal pain f. projectile vomiting g. bilious vomiting h. red, currant-jelly like stools i. olive shaped mass in RUQ

A, D, G

Intussusception characteristics: a. foul-smelling, ribbon-like stools b. sausage shaped abdominal mass c. constant hunger d. failure to pass meconium within 48 hours after birth e. sudden, episodic abdominal pain f. projectile vomiting g. bilious vomiting h. red, currant-jelly like stools i. olive shaped mass in RUQ

B, E, H

The parent of a 3-week-old with clubfoot states the infant was recasted this morning and has been crying for the past hour. Which intervention should the nurse suggest the parent do first? A.Administer pain medication B.Check circulation in the foot C.Use a blow drier with cool air to help relieve itching D.Reposition the infant with the legs elevated

B. Circulation is our main concern. We can reposition, give medication, and help relieve itching after ensuring circulation.

When caring for a child who has Hirschsprung's disease, which of the following actions should the nurse take? A.Encourage a high-fiber, low-protein, low-calorie diet B.Prepare the family for surgery C.Insert a NG tube to decompress D.Initiate strict bed rest

B. The client will be prepared for surgery to remove the affected intestine. The diet should be low-fiber, high-protein, high-calorie. Bed rest and NGT are not indiciated.

Which description of a stool is characteristic of intussusception? A.Hard stools positive for guaiac B.Currant-jelly like stool C.Ribbon-like stool D.Loose, foul-smelling stool

B. With intussusception, passage of bloody mucus-coated stools occurs. Pressure on the bowel from obstruction leads to passage of "currant jelly" stools. Ribbon-like stools are characteristic of Hirschsprung's disease. Stools will not be hard. Loose, foul-smelling stools may indicate infectious gastroenteritis.

In caring for the child with nephrosis, what is the desired outcome? A.Reduce blood pressure B.Reduce excretion of protein in the urine C.Increase excretion of protein in the urine D.Increase tissues ability to retain fluid

B. With nephrosis, we want to reduce protein being excreted through the urine, reduce fluid retention, prevent infection. Blood pressure is usually not elevated. Urinary protein loss and tissues retaining fluid are part of the disease process that we are working against.

Hemolytic Uremic Syndrome (HUS) characteristics: a. oliguria b. dark, frothy urine c. generalized edema d. cola or tea-colored urine e. facial edema f. recent diarrhea g. post-streptococcal infection

C, F

Pyloric Stenosis characteristics: a. foul-smelling, ribbon-like stools b. sausage shaped abdominal mass c. constant hunger d. failure to pass meconium within 48 hours after birth e. sudden, episodic abdominal pain f. projectile vomiting g. bilious vomiting h. red, currant-jelly like stools i. olive shaped mass in RUQ

C, F, I

What is a common side effect of corticosteroid therapy? A.Fever B.Weight loss C.Increased appetite D.Hypotension

C. Corticosteroids can increase appetite and lead to weight gain.

The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? A.Abdominal rigidity and pain with palpation B.Rounded abdomen and hypoactive bowel sounds C.Visible peristalsis and weight loss D.Distention of lower abdomen and constipation

C. Visible gastric peristaltic waves that move from left to right across the epigastrium are observed in pyloric stenosis, as is weight loss. Abdominal rigidity and pain on palpation, and rounded abdomen and hypoactive bowel sounds, are usually not present. The upper abdomen is distended, not the lower abdomen.

A 15-year-old diagnosed with scoliosis is to wear her brace for 23 hours a day. What is the most likely reason the child will not be compliant with wearing her brace? A.Pain from the brace B.Not understanding why she needs to wear the brace C.Difficulty putting the brace on D.Self-consciousness about the appearance

D. Children are very self-conscious about how the brace might appear. They may not fully understand why they need to wear it, but self-conscious will often result in noncompliance.

The nurse is providing teaching to parents with a child who has enuresis. Which of the following statements by the parent indicates understanding of behavioral therapy management for enuresis? A."We will not wake him up at night to use the bathroom." B."We will scold him when he wets the bed to ensure he understands." C."We will purchase a urine sensor alarm." D."We will reward him when he has dry nights."

D. The child should be rewarded for positive behaviors. They should not be scolded. Waking them up at night would help reduce occurrence. A urine alarm is a conditioning therapy and would not be first line treatment.

A nurse is caring for an infant who had a cleft lip and palate repair 6 hours ago. Which of the following actions should the nurse take? A.Remove the packing in the mouth B.Offer a pacifier with sucrose C.Assess the mouth with a tongue blade D.Assess skin under restraints

D. The infant will likely be in restraints (elbow) to prevent them from touching the incision site. Packing is not removed. The infant should not be sucking or have things placed in the mouth that can cause trauma to the sutures.

T or F. The nurse caring for an infant with strabismus tells the concerned parent that there is no need to correct the visual disorder until the child reaches school age.

False. The nurse caring for a child with strabismus accurately explains to the parents that treatment should begin in infancy in order to preserve normal development of visual acuity. Rationale: Children with strabismus cannot focus properly, so cannot successfully develop visual acuity. The infant and young child's brain needs to be able to process the correctly fused image in order to develop the part of the brain responsible for visual perception.

The nurse is preparing to explain the proper use and reasoning behind Kegel exercises, what should she discuss with her client to ensure the client understand the reasoning and proper steps for completing these exercies?

Identify the correct pelvic floor muscles by contracting them to stop the flow of urine while sitting on the toilet. Repeat this contraction several times to become familiar with it. Start the exercises by emptying the bladder. Tighten the pelvic floor muscles and hold for 10 seconds. Relax the muscles completely for 10 seconds. Perform 10 exercises at least three times daily. Progressively increase the number you perform. Perform the exercises in different positions, such as standing, lying, and sitting. Keep breathing during the exercises. Don't contract your abdominal, thigh, leg, or buttocks muscles during these exercises. Relax while doing pelvic floor muscle training exercises, and concentrate on isolating the right muscles. Attempt to tighten your pelvic muscles before sneezing, jumping, or laughing. Remember that you can perform these exercises anywhere without anyone noticing.

When compared with adults, why are infants and children at an increased risk of head trauma? a. the head of the infant and young child is large in proportion to the body and the neck muscles are not well developed b. the development of the nervous system is complete at birth but remains immature c. the spine is very immobile in infants and young children d. the spine is more flexible due to the presence of sutures and fontanels

The correct response is A. Infants and young children have a larger head size in relation to the body and a higher center of gravity. Both cause them to hit their head more readily when involved in motor vehicle accidents, bicycle accidents, and falls.

Which situation would cause the nurse to become concerned about possible hearing loss? a. A 12-month-old who babbles incessantly making no sense b. an 8-month-old who says only "da" c. a 3-month-old who startles easily to sound d. a 3-year-old who drops the letter "s"

The correct response is b. Infants should be babbling at the age of 8 months. Lack of babbling is an indicator of possible hearing loss.

Postpartum breast engorgement occurs 48-72 hours after giving birth. What physiologic change influences breast engorgement? a. increase in blood and lymph supply to the breasts b. increase in estrogen and progesterone levels c. dramatic increase in colostrum production d. fluid retention in the breasts due to the intravenous fluids given during labor

The correct response is A. Engorgement refers to the swelling of the breast tissue as a result of an increase in blood and lymph supply to produce milk for the newborn. Estrogen and progesterone levels decrease, which allows prolactin to stimulate the glands to secrete milk. Their levels are restored when the first menses returns several weeks or months later, depending on the lactation status of the mother. Colostrum is a lemon-colored fluid secreted by both breasts immediately at birth, and within 4 to 5 days postpartum it gradually changes to transitional milk and finally mature milk by 2 weeks. Colostrum production reduces within days after childbirth as transitional and mature milk, thereby not contributing to breast engorgement.

The nurse would expect a postpartum woman to experience lochia in which sequence? a. rubra, alba, serosa b. rubra, serosa, alba c. serosa, alba, rubra d. alba, rubra, serosa

The correct response is A. Engorgement refers to the swelling of the breast tissue as a result of an increase in blood and lymph supply to produce milk for the newborn. Estrogen and progesterone levels decrease, which allows prolactin to stimulate the glands to secrete milk. Their levels are restored when the first menses returns several weeks or months later, depending on the lactation status of the mother. Colostrum is a lemon-colored fluid secreted by both breasts immediately at birth, and within 4 to 5 days postpartum it gradually changes to transitional milk and finally mature milk by 2 weeks. Colostrum production reduces within days after childbirth as transitional and mature milk, thereby not contributing to breast engorgement.

The major purpose of the first postpartum home care visit to a. identify complications that require interventions b. obtain a blood specimen for PKU c. complete the official birth certificate d. support the new parents in their parenting roles

The correct response is A. Home visits are usually made within the first week of discharge to assess the mother and newborn. This visit is made primarily to provide the nurse with the opportunity to recognize common biomedical and psychosocial problems or complications. Although not the primary reason, this visit also offers an opportunity to provide support and guidance to the parents in making the adjustment to the change in their lives. The home visit is not the time to complete PKU testing or complete the birth certificate.

Late signs of increased intracranial pressure

decreased LOC, fixed and dilated pupils, cheyne-stokes respirations, decerebrate/decorticate posturing

A postpartum woman reports hearing voices and says, "the voices are telling me to do bad things to my baby," the clinic nurse interprets these findings as suggesting postpartum: a. psychosis b. anxiety disorder c. depression d. blues

The correct response is A. Psychotic persons tend to lose touch with reality and frequently attempt to harm themselves or others. This behavior may occur when a woman experiences postpartum psychosis. Anxiety typically does not induce hallucinations or cause a person to want to harm herself or others. Depression involves feelings of sadness rather than hallucinations or thoughts of harming herself or others. Feeling "down," but not to the extreme of wanting to harm herself or her newborn, is suggestive of postpartum blues.

Which factor in a postpartum woman's history would lead the nurse to monitor the woman closely for an infection? a. hgb of 12 b. manually extracted placenta c. labor of 10 hours in length d. multiparity of five pregnancies

The correct response is B since manual removal of a placenta increases the risk for infection since the uterus was entered and traumatized during the procedure. This extraction places her at high risk for a subsequent infection.

The nurse is instructing the postpartum client who plans to bottle-feed her newborn about measures to prevent breast engorgement when she is discharged. Which measure should the nurse include in the teaching plan? a. decreasing her fluid intake for the first week at home b. wearing a tight-fitting bra for 34 hours daily c. take a diuretic to release the extra fluid in the breasts d. manually express the milk that is accumulating

The correct response is B since wearing a supportive bra will decrease the discomfort and provide support for the heavy breasts. Engorgement will improve within 24 to 48 hours, although the milk supply may take several weeks to resolve. Responses A and C are incorrect since this is harmful advice to give a postpartum woman. Extra intake of fluids is recommended, not a reduction of them to keep her hydrated. Response D is incorrect since no attempt should be made to express milk from the breasts, as this will simply promote milk let down and further milk production and increase engorgement.

A 6-month-old infant is admitted to the hospital with suspected bacterial meninges. She is crying, irritable, and lying in the opisthotonic position. The priority nursing intervention would be a. educate the family on ways to prevent bacterial meningitis b. initiate appropriate isolation precautions and begin intravenous antibiotics c. assess the infant's fontanels d. encourage the mother to hold the infant and feed her

The correct response is B. Bacterial meningitis is a medical emergency and requires prompt hospitalization and treatment. Deterioration may be rapid and may occur in less than 24 hours, leading to long-term neurologic damage, and even death. Intravenous antibiotics will be started immediately after the LP and blood cultures have been obtained. Appropriate isolation needs to be initiated in any child with suspected or diagnosed bacterial meningitis.

Which suggestion would be most appropriate to include in the teaching plan for a postpartum woman who needs to lose weight? a. increase fluid intake and acid-producing foods in her diet b. avoid empty-calorie foods, breastfeed, and increase exercise c. start a high-protein, low carb diet and restrict fluids d. eat no snacks or carbohydrates after dinner

The correct response is B. Because weight loss is based on the principle of intake of calories and output of energy, instructing this woman to avoid high-calorie foods that yield no nutritive value and expending more energy through active exercise would result in weight loss for her.

While assessing a postpartum multiparous woman, the nurse detects a boggy uterus midline 2 cm above the umbilicus. Which intervention would be the priority? a. assess VS immediately b. measuring her next urinary output c. massage her fundus d. notifying the woman's obstetrician

The correct response is C. A boggy uterus that is midline and above the umbilicus suggests that the uterus is not contracting properly. Therefore, the nurse should massage the fundus to aid in stimulating the uterine muscles to contract. In addition, the nurse should assess the client's lochia.

Which activity would the nurse include in the teaching plan for parents with a newborn and an older child to reduce sibling rivalry when the newborn is brought home? a. punishing the older child for bedwetting behavior b. sending the sibling to the grandparents' house c. planning a daily "special time" for the older child d. allowing the sibling to share a room with the infant

The correct response is C. An older sibling needs to feel he or she is still loved and not upstaged by the newest family member. Allowing special time for that sibling reinforces the parent's love for him or her also. Regression behavior is common when there is stress in that sibling's life, and punishing him brings attention to negative behavior, possibly reinforcing it.

Which would the nurse expect to include in the plan of care for a woman with mastitis who is receiving antibiotic therapy? a. stop breastfeeding and apply lanolin b. administer analgesics and bind both breasts c. apply warm or cold compresses and administer analgesics d. remove the nursing bra and expose the breast to fresh air

The correct response is C. Applying compresses and giving analgesics would be helpful in providing comfort to the woman with painful breasts. Treatment for mastitis encourages frequent breast-feeding to empty the breasts.

At a well-child visit, hydrocephalus may be suspected in an infant if upon assessment the nurse finds a. narrow sutures b. sunken fontanels c. rapid increase in head circumference d. increase in weight since last visit

The correct response is C. In the infant, the most obvious indication of hydrocephalus is often a rapid increase in head circumference. Assessment may also reveal bulging, tense fontanels with widening sutures.

A postpartum mother appears very pale and states she is bleeding heavily. The nurse should first: a. call healthcare provider immediately b. immediately set up an IV infusion of magnesium sulfate c. assess the fundus and ask her about her voiding status d. reassure the mother that this is a normal finding after childbirth

The correct response is C. It is important to assess the situation before intervening. In addition, checking the bladder status and emptying a full bladder will correct uterine displacement so that effective contractions to stop bleeding can occur. Assessment of the situation is needed before the nurse can notify the health care provider. At this point, the nurse has no facts to report about the client's condition. Magnesium sulfate would relax the uterus and increase bleeding. Pallor and heavy bleeding are not normal findings during the postpartum period.

Early signs of increased intracranial pressure

headache, projectile vomiting, changes in LOC, bulging fontanel, increasing head circumference, changes in pupil reactions

After teaching a group of breastfeeding women about nutritional needs, the nurse determines that the teaching was successful when the women states that they need to increase intake of which nutrients? a. carbs and fiber b. fats and vitamins c. calories and protein d. iron-rich foods and minerals

The correct response is C. Lactating mothers need an extra 500 calories to sustain breast-feeding. An additional 20 g of protein is also needed to help build and regenerate body cells for the lactating woman. Additional intake of carbohydrates or fiber is not suggested for lactation.

When assessing a postpartum woman, which finding would lead the nurse to suspect postpartum blues? a. panic attacks and suicidal thoughts b. anger towards self and infant c. periodic crying and insomnia d. obsessive thoughts and hallucinations

The correct response is C. Periodic crying and insomnia are characteristics of postpartum blues, in addition to mood changes, irritability, and increased sensitivity. Panic attacks and suicidal thoughts or anger toward self and the infant would be descriptive of postpartum psychosis, when some women turn this anger toward themselves and have committed suicide or infanticide. Women experiencing postpartum blues do not lose touch with reality. Obsessive thoughts and hallucinations would be more descriptive of postpartum psychosis.

The nurse is assessing Ms. Smith who gave birth to her first child 5 days ago. What findings would the nurse expect? a. cream-colored lochia; uterus above the umbilicus b. bright red lochia with clots; uterus 2 finger-breadths below umbilicus c. light pink or brown lochia; uterus 4-5 fingerbreadths below umbilicus d. yellow, mucousy lochia; uterus at the level of the umbilicus

The correct response is C. The nurse would expect light pink or brown lochia, and the uterus should be four to five fingerbreadths below the umbilicus. Cream-colored lochia wouldn't be seen for about 10 to 14 days after childbirth, thus it wouldn't be observed this early in the postpartum period. The uterus would be involuting downward into the pelvis, thus it would not be above the umbilicus by this timeframe. Bright-red lochia would be observed for up to 3 days post birth, not 5 days later unless there was a problem. The uterus descends into the pelvis at a rate of 1 cm/day, thus the fundus should be 4 to 5 cm (fingerbreadths) below the umbilicus by now.

Which finding would lead the nurse to suspect that a woman is developing a postpartum complication? a. moderate lochia rubra for the first 24 hours b. clear lung sounds upon auscultation c. temp of 100F d. chest pain experienced when ambulating

The correct response is D as this may suggest a pulmonary embolism and the health care provider needs to be notified immediately.

Which assessment finding indicates positive bonding between the parents and the newborn? a. holding the infant close to the body b. having visitors hold the infant clothes c. buying expensive infant clothes d. requesting that the nurses care for the infant

The correct response is D. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention. Fatigue and irritability are not complications of childbearing, but rather the norm during the early postpartum period secondary to infant care demands and lack of sleep on the caretaker's part. Perineal discomfort and lochia serosa are normal physiologic events after childbirth and indicate normal uterine involution. Bradycardia is a normal vital sign for several days after childbirth because of the dramatic circulatory changes that take place with the loss of the placenta at birth and the return of blood back to the central circulation.

Which finding would lead the nurse to suspect that a postpartum woman was developing a complication? a. fatigue and irritability b. perineal discomfort and pink discharge c. pulse rate of 60 bpm d. swollen, tender, hot area on the breast

The correct response is D. A swollen, tender area on the breast would indicate mastitis, which would need medical intervention. Fatigue and irritability are not complications of childbearing, but rather the norm during the early postpartum period secondary to infant care demands and lack of sleep on the caretaker's part. Perineal discomfort and lochia serosa are normal physiologic events after childbirth and indicate normal uterine involution. Bradycardia is a normal vital sign for several days after childbirth because of the dramatic circulatory changes that take place with the loss of the placenta at birth and the return of blood back to the central circulation.

When implementing the plan of care for a multigravida postpartum woman who gave birth just a few hours ago, the nurse vigilantly monitors the client for which complication? a. DVT b. postpartum psychosis c. uterine infection d. postpartum hemorrhage

The correct response is D. Hemorrhage is possible if the uterus cannot contract and clamp down on the vessels to reduce bleeding. When the placenta is expelled, open vessels are then exposed and the risk of hemorrhage is great.

Methergine has been ordered for a postpartum woman because of excessive bleeding. The nurse should question this order if which of the following is present? a. Mild abdominal cramping b. Tender inflamed breasts c. Pulse rate of 68 beats per minute d. Blood pressure of 158/96 mmHg

The correct response is D. Methergine can cause hypertension. Therefore, if the woman's blood pressure was already elevated, the nurse would need to question the order for the drug. Typically if methergine is ordered, her lochia flow would be increased, not minimal.

Which of these activities would best help the postpartum nurse provide culturally sensitive care for the childbearing family? a. taking a transcultural course b. caring for only families of the nurse's cultural origin c. teaching western beliefs to culturally diverse families d. educating themselves about diverse cultural practices

The correct response is D. Nurses need first to become educated about various cultural practices to incorporate them into their care delivery. By gaining an understanding of diverse cultures different from their own, nurses can become sensitive to these different practices and not violate them.

A 10-year-old child is admitted to the hospital die to history of seizure activity. As his nurse, you are called into the room by his mother, who states he is having a seizure. What would be the priority nursing intervention? a. prevention of injury by removing the child from his bed b. prevention of injury by placing a tongue blade in the child's mouth c. prevention of injury by restraining the child d. prevention of injury by placing the child on his side and opening his airway

The correct response is D. Placing the child on his side and opening his airway can help prevent aspiration.

After the nurse provides instructions to a postpartum woman about postpartum blues, which statement indicates understanding? a. I will need medication daily to treat the anxiety and sadness b. I will call the OB support line only if I start to hear voices c. I will contact my doctor if I become dizzy and feel nauseated d. I will feel like laughing one minute and crying the next minute

The correct response to this question is D because emotional lability is typical of postpartum blues which is usually self-limiting. Response A is incorrect since postpartum blues don't require any medication to treat. Response B is incorrect since this behavior would indicate postpartum psychosis and not merely the "blues." Response C would indicate a physical condition, such as infection, not a mental disorder.

T or F. The nurse caring for children with visual disorders accurately states that the most common visual difficulty seen in children is refractive errors.

True. The most common visual difficulty seen in children is refractive errors. Rationale: Refractive errors occur when the light that enters the lens does not bend appropriately to allow it to fall directly on the retina.

The nurse is reviewing the blood urea nitrogen (BUN) results of an assigned client. The test is elevated. What factors may be associated with this result? Select all that apply. a. The child may be dehydrated. b. There may be an infectious process in the child. c. The child has type 1 diabetes mellitus. d. The child may be experiencing water intoxication. e. The child's diet contains high levels of protein.

a, b, e. Blood urea nitrogen may be elevated with a high-protein diet or dehydration, and may be decreased with overhydration or water intoxication. There is no direct link between this test and the presence of diabetes mellitus. BUN levels may be increased with an infectious process such as glomerulonephritis.

A hospitalized child is scheduled for magnetic resonance imaging (MRI) with contrast. What nursing interventions will the nurse complete to ensure safety during the examination? (select all that apply) a. place the child in clothing with no metal b. connect the child to a heart monitor c. assess the IV site for patency d. review any prescriptions for sedation e. assess for a latex allergy

a, c, d

The nurse is explaining ways to cope with postpartum blues, which of the following statements confirm the client understands how to cope with the blues? (select all that apply) a. "I will remember that blues are normal" b. "I need to work when the baby is sleeping" c. "I need to give me and my baby time to learn how to breastfeed" d. "I need to plan a day to get out of the house every now and then" e. "I don't need to tell my partner how I feel because it will only stress them out more"

a, c, d Rationale: Postpartum blues are normal and expected in some clients. Responses stating they understand, know what to expect, and coping mechanisms are encouraged. They should take time to rest while the baby is resting and should not avoid talking about their feelings.

The nurse is caring for a 14-year-old boy in Buck traction for a slipped capital femoral epiphysis (SCFE). What information would the nurse include when completing a neurovascular assessment of the affected leg? Select all that apply. a. Pulse b. Vital signs c. Color d. Sensation e. Capillary refill

a, c, d, e

The nurse is caring for a postpartum client when she notices that the client has persistent and significant bleeding, states she is weak and lightheaded, has a pulse of 129, and a decreased blood pressure. Which of the following steps should the nurse complete? (SATA) a. notify the obstetric health care provider b. give oxygen by nonrebreather face mask at 20 L/min c. massage the "boggy" fundus d. monitor VS e. prepare to administer blood products as ordered

a, c, d, e. Rat: Never give O2 at 20L

The emergency department nurse is caring for a 3-year-old girl with an arm injury. The mother is very upset because she believes she broke her daughter's arm. "I was lifting her by her hands and felt a pop in her wrist. She instantly started screaming." The child is now guarding and refusing to move her arm. Which response by the nurse would be most appropriate? a. "Her arm isn't broken. This injury is common and easily fixed with no complications." b. "This is most likely nursemaid's elbow; you will have to be more careful in the future." c. "You probably dislocated her radial head when you lifted her." d. "The popping noise was the ligament surrounding the radial head becoming entrapped."

a. The nurse should quickly reassure the mother that this is a common occurrence, seen every day in the emergency department, and is easily fixed and resolves with no complications. Although a popping noise indicates entrapment of the ligament, this response does not address the mother's concerns. Although the radial head most likely dislocated, this response does not address the mother's concern. Although this condition is called nursemaid's elbow, telling the mother she has to be more careful only serves to put blame on the mother and does not address her concerns.

The nurse observes a child for neurologic disorders. What is the earliest indicator of improvement or deterioration of neurologic status? a. Vital signs b. Level of consciousness c. Motor function d. Reflexes

b

The nurse is percussing the chest of a child with a suspected respiratory disorder. What sound might the nurse note that would indicate pneumonia? a. Decreased fremitus b. Dull sound c. Tympany d. Hyperresonance

b. Dull sound A dull or flat sound would be percussed over partially consolidated lung tissue, as occurs with pneumonia. Decreased fremitus is found on palpation and may be found with barrel chest, as may occur with cystic fibrosis. Tympany might be percussed with pneumothorax, and hyperresonance might be apparent with asthma.

A nurse is conducting a physical examination on an 11-year-old boy with Legg-Calvé-Perthes disease. Which assessment finding would be expected? a. Kyphosis b. Trendelenburg gait c. Lordosis d. Loss of strength in ankle dorsiflexion

b. The nurse would expect to note a Trendelenburg gait due to pain. Lordosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Kyphosis is an excessive curvature of the spine and is not associated with Legg-Calvé-Perthes disease. Loss of strength in ankle dorsiflexion is associated with some neuromuscular disorders but not this condition.

The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy? a. large doses of vitamin C during pregnancy b. prophylactic antibiotics c. strict aseptic technique, including hand washing, by all health care personnel d. limited protein and fat intake

c

Which signs best indicate increased intracranial pressure (ICP) in an infant? (select all that apply) a. sunken anterior fontanel b. complaints of blurred vision c. high-pitched cry d. increased appetite e. sleeping more than usual

c, e. Rat: anterior fontanel is usually raised, bulging. Not able to comprehend and communicate blurred vision. Appetite is usually poor and infant does not feed well.

The nurse is caring for a 3-year-old boy with a fracture of the humerus. His chart indicates "fracture is partially through the physis extending into the metaphysis." The nurse identifies this as which Salter-Harris classification? a. Type IV b. Type I c. Type II d. Type V

c. According to the Salter-Harris classification, a type II fracture is partially through the physis extending into the metaphysis. A type I fracture is through the physis, widening it. A type IV fracture is through the metaphysis, physis, and epiphysis. A type V fracture is a crushing injury to the physis.

The nurse is caring for a 10-year-old girl in traction. The girl is experiencing muscle spasms associated with the traction. What would the nurse expect to administer if ordered? a. Narcotic analgesics b. Alendronate c. Diazepam d. Pamidronate

c. Diazepam is an antianxiety drug that also has the effect of skeletal muscle relaxation; it is used for the treatment of muscle spasm associated with traction or casting. Narcotic analgesics are used for pain relief. Alendronate increases bone mineral density for children with osteogenesis imperfecta. Pamidronate increases bone mineral density for children with osteogenesis imperfecta.

The nurse is caring for a child with rickets. Which diagnostic test result would the nurse expect to find in the child's medical record? a. X-ray confirmation of adequate bone shape b. High serum phosphate levels c. Low serum calcium levels d. Low alkaline phosphate levels

c. With rickets, serum calcium and phosphate levels are low and alkaline phosphate levels are elevated. Radiographs show changes in the shape and structure of the bone.

The nurse is performing a diagnostic test to determine the extent of tympanic membrane movement. What is the name for this test? a. Culture of ear discharge b. Tympanic fluid culture c. Tympanometry d. Tympanostomy

c. With tympanometry, a probe in the ear canal measures movement of the eardrum to help determine effusion in the middle ear. Ear discharge or tympanic fluid cultures determine presence of specific bacteria. Tympanostomy is not a diagnostic test, but rather ear tube surgery.

A 30-year-old multiparous woman has a boy who is 2 1/2 years old and now an infant girl. She tells the nurse, "I don't know how I'll ever manage both children when I get home." Which suggestion would best help this woman alleviate sibling rivalry? A. Tell the older child that he is a big boy now and should love his new sister B. Let the older child stay with his grandparents for the first 6 weeks to allow him to adjust to the newborn C. Ask friends and relatives not to bring gifts to the older sibling because you do not want to spoil him D. Realize that the regression in habits and behaviors in the older child is a typical reaction and that he needs extra love and attention at this time

d

The nurse is assisting with testing on a newborn suspectedd of having a neural tube defect. Which diagnostic test would be used to confirm this condition? a. lumbar puncture b. electroencephalogram c. fluoroscopy d. MRI

d

Which of the following responses by an after birth woman indicates she understands teaching regarding the correct process of pelvic floor exercises? a. "I contract my thighs, buttocks, and abdomen" b. "I do 10 of these exercises every day" c. "I stand while practicing this new exercise routine." d. "I pretend that I am trying to stop the flow of urine midstream"

d

The nurse is caring for a child recently fitted with braces on both legs due to cerebral palsy (CP). What would the nurse emphasize in the discharge teaching? a. "Please try and follow the therapist's on and off schedule." b. "If the brace is painful, feel free to take it off." c. "It is very important to comply with the use of this brace." d. "Check the skin that is covered by the braces for redness and breakdown."

d. Assessing skin integrity should be the priority, as braces can lead to pressure ulcers and infection. Compliance is important, but attention to skin care is the priority teaching. Following the schedule is important for compliance, but skin integrity is the priority. Advising the parents to remove the brace if it is painful is inaccurate; the child may require pain management or further consultation with the physical therapist.

After teaching a group of students about medications commonly used for neuromuscular disorders, the nursing instructor determines that the teaching was successful when the students identify which agent as a centrally acting skeletal muscle relaxant? a. Prednisone b. Botulin toxin c. Lorazepam d. Baclofen

d. Baclofen is a centrally acting skeletal muscle relaxant used to treat painful spasms and decrease spasticity in children with motor neuron lesions. Prednisone is a corticosteroid that is used to help slow the progression of Duchenne muscular dystrophy. Lorazepam is a benzodiazepine used for adjunctive relief of skeletal muscle spasm associated with cerebral palsy. Botulin toxin is a neurotoxin used to relieve spasticity in cerebral palsy.

The nurse is caring for a child with cystic fibrosis. Which of the following treatments would be used to promote mucus clearance through percussion or vibration? a. Suctioning b. Chest tube c. Bronchoscopy d. Chest physiotherapy

d. Chest physiotherapy Chest physiotherapy promotes mucus clearance through percussion or vibration. Suctioning removes secretions via bulb syringe or suction catheter, chest tubes remove air or fluid though a drain inserted into the pleural cavity, and bronchoscopy is the introduction of a bronchoscope into the bronchial tree for diagnostic purposes.

The nurse is teaching the parents of a female child with a myelomeningocele how to perform clean intermittent catheterization. The nurse determines that the teaching was effective when the parents return demonstrate the procedure and state: a. "We need to insert the catheter about 6 inches so that we make sure the catheter is in the bladder." b. "We need to apply some petroleum jelly to her labia and the catheter before we attempt to insert it." c. "Before inserting the catheter, we need to wipe her labia with normal saline from back to front." d. "When the urine stops flowing, we should press on the lower belly to ensure the bladder is empty."

d. When the urine stops flowing, the parents should press on the lower abdomen or have the child lean forward to tense the abdominals to ensure that no more urine is in the bladder. For a female, the catheter is inserted about 2 to 3 inches. For a male, the catheter is inserted about 4 to 6 inches. Before the catheter is inserted, the labia is cleaned with a washcloth or disposable wipe from front to back. A generous amount of water-soluble lubricant, not petroleum jelly, is applied to the catheter. There is no need to apply the lubricant to the labia.