Q2 Midterm Test practice
Inspect, Palpate, Percuss, Auscultate
The nurse is teaching the student nurse the sequence for performing the assessment techniques during a physical examination. What is the appropriate order?
anemia
The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition?
Paraphrase the child's or parent's feelings to demonstrate empathy.
The nurse is using verbal skills to explain the nursing care plan to parents of a 10- year-old child with cancer. Which of the following describes a guideline the nurse should follow to provide appropriate verbal communication?
1.Around 2 months the infant exhibits a first real smile. 2.Around 3 months the infant smiles widely and gurgles when interacting with the caregiver. 3.Around 3 months the infant will mimic the parent's facial movements, such as sticking out the tongue. 4.Separation anxiety may also start in the last few months of infancy.
The nurse observes an infant interacting with his parents. Which of the following are normal social behavioral developments for this age group? Select all answers that apply.
Endocrine
The nurse performing a health history on a child asks the parents if their child has experienced increased appetite or thirst. What body system is the nurse assessing with this question?
"Thumb sucking is a healthy self-comforting activity."
The parent of a 6-month old infant asks the nurse for advice about his son's thumb sucking. What would be the nurse's best response to this parent?
21.4
Assessment reveals that a child weighs 73 lb and is 4 ft 1 in. tall. The nurse calculates this child's body mass index as:
"When my 3-year-old asks 'why?' all the time, this is completely normal."
After teaching a group of parents about language development in toddlers, which of the following if stated by a member of the group indicates successful teaching?
4 months
At which age would the nurse expect to find the beginning of object permanence?
"We keep a strict bedtime ritual for our son, which includes a bath and bedtime story."
During a health history, the nurse explores the sleeping habits of a 3-yearold boy by interviewing his parents. Which of the following statements from the parents reflects a recommended guideline for promoting healthy sleep in this age group?
1.At 1 month the infant lifts and turns the head to the side in the prone position. 2.At 7 months the infant sits alone with some use of hands for support. 3.At 9 months the infant crawls with the abdomen off the floor. 4.At 12 months the infant walks independently.
The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which of the following statements accurately describe the typical infant's achievement of these milestones?
There is an increased risk for physical injury in this age group.
The nurse emphasizes that a toddler younger than the age of 18 months should never be spanked primarily for which reason?
Asking the mother if the child uses Spanish words
The nurse is assessing a 12-month-old boy with an English-speaking father and a Spanish-speaking mother. The boy does not say mama or dada yet. Which of the following is the priority intervention?
The child does not babble or laugh.
The nurse is assessing a 4-month-old boy during a scheduled visit. Which of the following findings might suggest a developmental problem?
1.The nasal passages are narrower. 2.The larynx is more funnel shaped. 3.There are significantly fewer alveoli.
The nurse is assessing the respiratory system of a newborn. Which of the following anatomic differences place the infant at risk for respiratory compromise?
axillary
The nurse is assessing the temperature of a diaphoretic toddler who is crying and being uncooperative. What would be the best method to assess temperature in this child?
Letting him choose juice or soda to take pills
The nurse is caring for a 14-year-old boy with an osteosarcoma. Which of the following communication techniques would be least effective for him?
Discussing the type of sippy cup to use
The nurse is caring for a 7-month-old girl during a well-child visit. Which of the following interventions is most appropriate for this child?
Knowing which are his or her toys
The nurse is caring for a toddler who is in Piaget's sensorimotor stage of cognitive development. Which of the following tasks would the nurse expect the toddler to be able to perform?
1.Sweet potatoes 2.Spinach 3.Carrots
The nurse is choosing foods for a toddler's diet that are high in vitamin A. Which of the following could be added to the menu?
Chief complaint
The nurse is conducting a physical examination of a child following a comprehensive health history. What should be the focus of the physical examination?
"He must be positioned on his tummy as much as possible."
The nurse is conducting a routine health assessment of a 3-month-old boy and notices a flat occiput. The nurse provides teaching and emphasizes the importance of tummy time. Which response indicates a need for further teaching?
1.Support before and after, but not during, medical procedures 2.Grief and bereavement support 3.Emergency room interventions for children and families
The nurse is consulting with a child life specialist (CLS) to help minimize the stress of hospitalization for a child. Which of the following services would the CLS provide?
Monitoring the toddler for developmental delays
The nurse is designing a nursing care plan for a toddler with lymphoma, who is hospitalized for treatment. Which of the following is a priority intervention that the nurse should include in this child's nursing plan?
Explaining that the stomach holds less than 1 ounce
The nurse is educating a first-time mother who has a 1-week-old boy. Which of the following is the most accurate anticipatory guidance?
Quiet alert state
The nurse is helping a new mother prepare for breastfeeding her infant. During which of the following newborn states of consciousness would the nurse recommended attempting the feeding?
1.Extending breastfeeding into toddlerhood is believed to be beneficial to the child. 2.Adequate calcium intake and appropriate exercise lay the foundation for proper bone mineralization. 3.The toddler requires an average intake of 500 mg calcium per day.
The nurse is helping parents prepare a healthy meal plan for their toddler. Which of the following guidelines for promoting nutrition should be followed when planning meals?
Appearance of pubic hair around 11 to 13 years old
The nurse is inspecting the genitals of a prepubescent girl. Which is a normal sign of the onset of puberty?
Lactose intolerance
The nurse is performing a health assessment of a 3-month-old Black American boy. For what condition should this infant be monitored based on his race?
Therapeutic hugging
The nurse is preparing a child and his family for a lumbar puncture. Which of the following would be a primary intervention instituted by the CLS to keep the child safe?
Direct the infrared sensor at the tympanic membrane
The nurse is preparing to take a tympanic temperature reading of a 4-year-old. In order to get an accurate reading, what does the nurse need to do?
Discouraging the addition of fruit juice to the diet
The nurse is promoting a healthy diet to guide a mother when feeding her 2-week-old girl. Which of the following is the most effective anticipatory guidance?
Advising how to create a toddler-safe home
The nurse is providing anticipatory guidance to the mother of a 9-month-old girl during a well-baby visit. Which of the following topics would be most appropriate?
1.Avoid or reduce painful procedures 2.Avoid or reduce physical distress 3.Use core primary nursing
The nurse is providing atraumatic care to children in a hospital setting. Which of the following are principles of this philosophy of care?
Do not add cereal to the formula in the bottle or sweeten the formula with honey.
The nurse is providing discharge teaching regarding formula preparation for a new mother. Which of the following guidelines would the nurse include in the teaching plan?
1.toileting habits 2.car seat use and safety measures 3.use of supplements and vitamins
The nurse is questioning the parents of a 2-year-old child to obtain a functional history. Which of the following topics might the nurse include?
By 6 months of age the infant's brain weighs half that of the adult brain; at age 12 months, the brain weighs 2.5 times what it did at birth.
The nurse is teaching a new mother about the drastic growth and developmental changes her infant will experience in the first year of life. Which of the following describes a developmental milestone occurring in infancy?
Bring the baby's wide-open mouth to the breast to form a seal around all of the nipple and areola.
The nurse is teaching a new mother the proper techniques for breastfeeding her newborn. Which of the following is a recommended guideline that should be implemented?
Do not blame toddlers for aggressive behavior; instead, point out the results of their behavior.
The nurse is teaching parents interventions appropriate to the emotional development of their toddlers. Which of the following is a recommended intervention for this age group?
Have the child help clean up a bowel accident.
The nurse is teaching the parents of a 2-year-old girl how to deal with common toddler situations. Which is the best advice?
Observation of a supernumerary nipple along the mammary ridge
The nurse is teaching the student nurse about abnormal findings when assessing the breasts of children. Which of the following may be associated with renal disorders?
Include the child in all parts of the examination; speak to the caregiver before and after the examination.
The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which of the following statements accurately describes a recommended guideline for setting the tone of the examination for a school-age child?
Tell the parents to limit the child's eating to meal and snack times.
The parents of a 1-year-old girl, both of whom have perfect teeth, are concerned about their child getting dental caries. Which is the best advice the nurse can provide?
"You need to adhere to various routines."
The parents of a 2-year-old girl are frustrated by the frequent confrontations they have with their child. Which is the best anticipatory guidance the nurse can offer them?
Approximately 16 to 24 ounces of milk per day
When instructing the parents of a toddler about appropriate nutrition, which of the following would the nurse recommend?
Climbing stairs with assistance
Which of the following would the nurse expect to find in an 18-month-old?
Step
Which reflex, if found in a 4-month-old infant, would cause the nurse to be concerned?
Grade 2
While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as which Grade of murmur?
