Complete Test Bank With Answers

Sample Questions Posted Below

Chapter 1 Perspectives on Maternal and Child Health Care

The United States ranks 50th in the world for maternal mortality and 41st among

industrialized nations for infant mortality rate. When developing programs to

assist in decreasing these rates, which factor would most likely need to be

addressed as having the greatest impact?

Resolving all language and cultural differences

Assuring early and adequate prenatal care

Providing more extensive womens shelters

Encouraging all women to eat a balanced diet

When integrating the principles of family-centered care, the nurse would include

which of the following?

Childbirth is viewed as a procedural event

Families are unable to make informed choices

Childbirth results in changes in relationships

Families require little information to make appropriate decisions

When preparing a teaching plan for a group of first-time pregnant women, the

nurse expects to review how maternity care has changed over the years. Which

of the following would the nurse include when discussing events of the

20th century?

Epidemics of puerperal fever

Performance of the first cesarean birth

Development of the x-ray to assess pelvic size

Creation of free-standing birth centers

After teaching a group of students about pregnancy-related mortality, the

instructor determines that additional teaching is needed when the students

identify which condition as a leading cause?

Hemorrhage

Embolism

Obstructed labor

Infection

The nurse is working with a group of community health members to develop a

plan to address the special health needs of women. Which of the following

conditions would the group address as the major problem?

Smoking

Heart disease

Diabetes

plan to address the special health needs of women. Which of the following

conditions would the group address as the major problem?

Smoking

Heart disease

Diabetes

Cancer

When assessing a family for possible barriers to health care, the nurse would

consider which factor to be most important?

Language

Health care workers attitudes

Transportation

Finances

After teaching a group of nursing students about the issue of informed consent.

Which of the following, if identified by the student, would indicate an

understanding of a violation of informed consent?

Performing a procedure on a 15-year-old without consent

Serving as a witness to the signature process

Asking whether the client understands what she is signing

Getting verbal consent over the phone for emergency procedures

The nurse is trying to get consent to care for an 11-year-old boy with diabetic

ketoacidosis. His parents are out of town on vacation, and the child is staying

with a neighbor. Which action would be the priority?

Getting telephone consent with two people listening to the verbal consent

Providing emergency care without parental consent

Contacting the childs aunt or uncle to obtain their consent

Advocating for termination of parental rights for this situation

After teaching nursing students about the basic concepts of family-centered care,

the instructor determines that the teaching was successful when the students state

which of the following?

Childbirth affects the entire family, and relationships will change.

Families are not capable of making health care decisions for themselves.

Mothers are the family members affected by childbirth.

Childbirth is a medical procedure.

A nursing instructor is preparing a class discussion on the trends in health care

and health care delivery over the past several centuries. When discussing the

changes during the past century, which of the following would the instructor be

least likely to include?

)

Disease prevention

)

Health promotion

)

Wellness

changes during the past century, which of the following would the instructor be

least likely to include?

)

Disease prevention

)

Health promotion

)

Wellness

)

Analysis of morbidity and mortality

A nurse is assigned to care for an Asian American client. The nurse develops a

plan of care with the understanding that based on this clients cultural

background, the client most likely views illness as which of the following?

)

Caused by supernatural forces.

)

A punishment for sins.

)

Due to spirits or demons.

)

From an imbalance of yin and yang

A nurse is developing a plan of care for a woman to ensure continuity of care

during pregnancy, labor, and childbirth. Which of the following would be most

important for the nurse to incorporate into that plan?

)

Adhering to strict, specific routines

)

Involving a pediatric physician

)

Educating the client about the importance of a support person

)

Assigning several nurses as a support team

)

Involving a pediatric physician

)

Educating the client about the importance of a support person

)

Assigning several nurses as a support team

A nursing instructor is preparing a class discussion on case management in

maternal and newborn health care. Which of the following would the instructor

include as a key component? Select all that apply.

)

Advocacy

)

Coordination

)

Communication

)

Resource management

)

Event managed care

After teaching a group of students about the concept of maternal mortality, the

instructor determines that additional teaching is needed when the students state

which of the following?

)

The rate includes accidental causes for deaths.

)

It addresses pregnancy-related causes.

)

The duration of the pregnancy is not a concern.

)

The time frame is typically for a specified year.

A group of students are reviewing the historical aspects about childbirth. The

students demonstrate understanding of the information when they identify the

use of twilight sleep as a key event during which time frame?

)

1700s

)

1800s

)

1900s

)

2000s

A nurse is providing care to a woman who has just delivered a healthy newborn.

Which action would least likely demonstrate application of the concept of

family-centered care?

)

Focusing on the birth as a normal healthy event for the family

)

Creating opportunities for the family to make informed decisions

)

Encouraging the woman to keep her other children at home

)

Fostering a sense of respect for the mother and the family

When discussing fetal mortality with a group of students, a nurse addresses

maternal factors. Which of the following would the nurse most likely include?

Select all that apply.

)

Chromosomal abnormalities

)

Malnutrition

)

Preterm cervical dilation

Underlying disease condition

maternal factors. Which of the following would the nurse most likely include?

Select all that apply.

)

Chromosomal abnormalities

)

Malnutrition

)

Preterm cervical dilation

)

Underlying disease condition

)

Poor placental attachment

A nurse is preparing a presentation for a local community group about health

status and childrens health. Which of the following would the nurse include as

one of the most significant measures?

)

Fetal mortality rate

)

Neonatal mortality rate

)

Infant mortality rate

)

Maternal mortality rate

A group of students are reviewing an article describing information related to

indicators for womens health and the results of a national study. Which of the

following would the students identify as being satisfactory for women? Select

all that apply.

)

Smoking cessation

)

Colorectal cancer screening

)

Violence against women

)

Health insurance coverage

Mammograms

)

Smoking cessation

)

Colorectal cancer screening

)

Violence against women

)

Health insurance coverage

)

Mammograms

A nurse is preparing a presentation for a local womens group about heart

disease and women. Which of the following would the nurse expect to address

when discussing measures to promote health.

)

Women have similar symptoms as men for a heart attack.

)

Heart disease is no longer viewed as a mans disease.

)

Women experiencing a heart attack are at greater risk for dying.

)

Heart attacks in women are more easily diagnosed.

A nurse is working to develop a health education program for a local

community to address breast cancer awareness. Which of the following would

the nurse expect to include when describing this problem to the group? Select

all that apply.

)

White women have higher rates of breast cancer than African American women.

)

African American women are more likely to die from breast cancer at any age.

)

Survival at any stage is worse among white women.

)

Women living in South America have the highest rates of breast cancer.

)

Breast cancer is the leading cause of cancer mortality in women.

)

African American women are more likely to die from breast cancer at any age.

)

Survival at any stage is worse among white women.

)

Women living in South America have the highest rates of breast cancer.

)

Breast cancer is the leading cause of cancer mortality in women.

A group of nursing students are reviewing information about factors affecting

maternal, newborn, and womens health. The students demonstrate

understanding of the information when they identify which of the following

deficiencies as being associated with poverty? Select all that apply.

)

Literacy

)

Employment opportunities

)

Mobility

)

Political representation

)

Skills

Chapter 2 Family-Centered Community-Based Care

The nurse is caring for a 2-week-old newborn girl with a metabolic disorder.

Which of the following activities would deviate from the characteristics of

family-centered care?

)

Softening unpleasant information or prognoses

)

Evaluating and changing the nursing plan of care

)

Collaborating with the child and family as equals

)

Showing respect for the familys beliefs and wishes

)

Softening unpleasant information or prognoses

)

Evaluating and changing the nursing plan of care

)

Collaborating with the child and family as equals

)

Showing respect for the familys beliefs and wishes

The nurse is providing home care for a 6-year-old girl with multiple medical

challenges. Which of the following activities would be considered the tertiary

level of prevention?

)

Arranging for a physical therapy session

)

Teaching parents to administer albuterol

)

Reminding parent to give a full course of antibiotics

)

Giving a DTaP vaccination at the proper interval

A nursing student is reviewing information about documenting client care and

education in the medical record and the purposes that it serves. The student

demonstrates a need for additional study when the nurse identifies which of the

following as a reason?

)

Serves as a communication tool for the interdisciplinary team.

)

Demonstrates education the family has received if legal matters arise.

)

Permits others access to allow refusal of medical insurance coverage.

)

Verifies meeting client education standards set by the Joint Commission.

A pregnant client tells her nurse that she is interested in arranging a home birth.

After educating the client on the advantages and disadvantages, which statement

would indicate that the client understood the information?

)

I like having the privacy, but it might be too expensive for me to set up in my

home.

)

I want to have more control, but I am concerned if an emergency would arise.

)

It is safer because I will have a midwife.

)

The midwife is trained to resolve any emergency, and she can bring any pain

meds.

The nurse is making a home visit to a client who had a cesarean birth 3 days ago.

Assessment reveals that the client is complaining of intermittent pain, rating it as

8 on a scale of 1 to 10. She states, Im pretty tired. And with this pain, I havent

been drinking and eating like I should. The medication helps a bit but not much.

My mom has been helping with the baby. Her incision is clean, dry, and intact.

Which nursing diagnosis would the nurse identify as the priority for this client?

)

Impaired skin integrity related to cesarean birth incision

)

Fatigue related to effects of surgery and caretaking activities

)

Imbalanced nutrition, less than body requirements related to poor fluid and food

intake

)

Acute pain related to incision and cesarean birth

When caring for childbearing families from cultures different from ones own,

which of the following must be accomplished first?

)

Adapt to the practices of the familys culture

)

Determine similarities between both cultures

Assess personal feelings about that culture

When caring for childbearing families from cultures different from ones own,

which of the following must be accomplished first?

)

Adapt to the practices of the familys culture

)

Determine similarities between both cultures

)

Assess personal feelings about that culture

)

Learn as much as possible about that culture

After teaching a group of students about the changes in health care delivery and

funding, which of the following, if identified by the group as a current trend seen

in the maternal and child health care settings, would indicate that the teaching

was successful?

)

Increase in community settings for care

)

Decrease in family poverty level

)

Increase in hospitalization of children

)

Decrease in managed care

The nurse would recommend the use of which supplement as a primary

prevention strategy to prevent neural tube defects with pregnant women?

)

Calcium

)

Folic acid

)

Vitamin C

)

Iron

)

Calcium

)

Folic acid

)

Vitamin C

)

Iron

Which action would the nurse include in a primary prevention program in the

community to help reduce the incidence of HIV infection?

)

Provide treatment for clients who test positive for HIV

)

Monitor viral load counts periodically

)

Educate clients in how to practice safe sex

)

Offer testing for clients who practice unsafe sex

When assuming the role of discharge planner for a woman requiring ventilator

support at home, the nurse would do which of the following?

)

Confer with the clients mother

)

Teach new self-care skills to the client

)

Determine if there is a need for back-up power

)

Discuss coverage with the insurance company

When comparing community-based nursing with nursing in the acute care

setting to a group of nursing students, the nurse describes the challenges

associated with community-based nursing. Which of the following would the

nurse include?

)

Increased time available for education

)

Improved access to resources

)

Decision making in isolation

)

Greater environmental structure

After teaching a group of students about the different levels of prevention, the

instructor determines a need for additional teaching when the students identify

which of the following as a secondary prevention level activity in communitybased

health care?

)

Teaching women to take folic acid supplements to prevent neural tube defects

)

Working with women who are victims of domestic violence

)

Working with clients at an HIV clinic to provide nutritional and CAM therapies

)

Teaching hypertensive clients to monitor blood pressure

A nursing instructor is describing trends in maternal and newborn health care.

The instructor addresses the length of stay for vaginal births during the past

decade, citing that which of the following denotes the average stay?

)

2448 hours or less

)

7296 hours or less

4872 hours or less

A nursing instructor is describing trends in maternal and newborn health care.

The instructor addresses the length of stay for vaginal births during the past

decade, citing that which of the following denotes the average stay?

)

2448 hours or less

)

7296 hours or less

)

4872 hours or less

)

96120 hours or less

Which of the following statements is accurate regarding womens health care in

todays system?

)

Women spend 95 cents of every dollar spent on health care.

)

Women make almost 90% of all health care decisions.

)

Women are still the minority in the United States.

)

Men use more health services than women.

A nurse is educating a client about a care plan. Which of the following

statements would be appropriate to assess the clients learning ability?

)

Did you graduate from high school; how many years of schooling did you have?

)

Do you have someone in your family who would understand this information?

)

Many people have trouble remembering information; is this a problem for you?

)

Would you prefer that the doctor give you more detailed medical information?

)

Did you graduate from high school; how many years of schooling did you have?

)

Do you have someone in your family who would understand this information?

)

Many people have trouble remembering information; is this a problem for you?

)

Would you prefer that the doctor give you more detailed medical information?

A nurse is developing cultural competence. Which of the following indicates

that the nurse is in the process of developing cultural knowledge? Select all that

apply.

)

Examining personal sociocultural heritage

)

Reviewing personal biases and prejudices

)

Seeking resources to further understanding of other cultures

)

Becoming familiar with other culturally diverse lifestyles

)

Performing a competent cultural assessment

)

Advocating for social justice to eliminate disparities.

A nurse is engaged in providing family-centered care for a woman and her

family. The nurse is providing instrumental support with which activity?

)

Explaining to the woman and family what to expect during the birth process.

)

Assisting the woman in breathing techniques to cope with labor contractions.

)

Reinforcing the womans role as a mother after birth

)

Helping the family obtain extra financial help for prescribed phototherapy

)

Explaining to the woman and family what to expect during the birth process.

)

Assisting the woman in breathing techniques to cope with labor contractions.

)

Reinforcing the womans role as a mother after birth

)

Helping the family obtain extra financial help for prescribed phototherapy

A nurse is considering a change in employment from the acute care setting to

community-based nursing. The nurse is focusing her job search on ambulatory

care settings. Which of the following would the nurse most likely find as a

possible setting? Select all that apply.

)

Urgent care center

)

Hospice care

)

Immunization clinic

)

Physicians office

)

Day surgery center

)

Nursing home

A nursing instructor is presenting a class for a group of students about

community-based nursing interventions. The instructor determines that

additional teaching is needed when the students identify which of the following?

)

Conducting childbirth education classes

)

Counseling a pregnant teen with anemia

)

Consulting with a parent of a child who is vomiting

)

Performing epidemiologic investigations

)

Conducting childbirth education classes

)

Counseling a pregnant teen with anemia

)

Consulting with a parent of a child who is vomiting

)

Performing epidemiologic investigations

During class, a nursing student asks, I read an article that was talking about

integrative medicine. What is that? Which response by the instructor would be

most appropriate?

)

It refers to the use of complementary and alternative medicine in place of

traditional therapies for a condition.

)

It means that complementary and alternative medicine is used together with

conventional therapies to reduce pain or discomfort.

)

It means that mainstream medical therapies and complementary and alternative

therapies are combined based on scientific evidence for being effective.

)

It refers to situations when a client and his or her family prefer to use an

unproven method of treatment over a proven one.

While a nurse is obtaining a health history, the client tells the nurse that she

practices aromatherapy. The nurse interprets this as which of the following?

)

Use of essential oils to stimulate the sense of smell to balance the mind and

body

)

Application of pressure to specific points to allow self-healing

)

Use of deep massage of areas on the foot or hand to rebalance body parts

)

Participation in chanting and praying to promote healing.

A pregnant woman asks the nurse about giving birth in a birthing center. She

says, Im thinking about using one but Im not sure. Which of the following

would the nurse need to integrate into the explanation about this birth setting?

(Select all that apply.)

)

An alternative for women who are uncomfortable with a home birth.

)

The longer length of stay needed when compared to hospital births

)

Focus on supporting women through labor instead of managing labor

)

View of labor and birth as a normal process requiring no intervention

)

Care provided primarily by obstetricians with midwives as backup care

A nurse practicing in the community is preparing a presentation for a group of

nursing students about this practice setting. Which of the following would the

nurse include as characteristic of this role?

)

Greater emphasis on direct physical care

)

Broader assessment to include the environment

)

Increased dependency on physician

)

Limited decision making and support

A nurse is preparing a teaching plan for a woman who is pregnant for the first

time. Which of the following would the nurse incorporate into the teaching plan

to foster the clients learning? (Select all that apply.)

)

Teach survival skills first

)

Use simple, nonmedical language

A nurse is preparing a teaching plan for a woman who is pregnant for the first

time. Which of the following would the nurse incorporate into the teaching plan

to foster the clients learning? (Select all that apply.)

)

Teach survival skills first

)

Use simple, nonmedical language

)

Refrain from using a hands-on approach

)

Avoid repeating information

)

Use visual materials such as photos and videos

A group of nurses are reviewing the steps for developing cultural competence.

The students demonstrate understanding when they identify which of the

following as the final step?

)

Cultural knowledge

)

Cultural skills

)

Cultural encounter

)

Cultural awareness

Chapter 3 Anatomy and Physiology of the Reproductive System

When describing the menstrual cycle to a group of young women, the nurse

explains that estrogen levels are highest during which phase of the endometrial

cycle?

)

Menstrual

)

Proliferative

)

Secretory

)

Ischemic

After teaching a group of adolescent girls about female reproductive

development, the nurse determines that teaching was successful when the girls

state that menarche is defined as a womans first:

)

Sexual experience

)

Full hormonal cycle

)

Menstrual period

)

Sign of breast development

A client with a 28-day cycle reports that she ovulated on May 10. The nurse

would expect the clients next menses to begin on:

)

May 24

)

May 26

)

May 30

)

June 1

A client with a 28-day cycle reports that she ovulated on May 10. The nurse

would expect the clients next menses to begin on:

)

May 24

)

May 26

)

May 30

)

June 1

Which female reproductive tract structure would the nurse describe to a group of

young women as containing rugae that enable it to dilate during labor and birth?

)

Cervix

)

Fallopian tube

)

Vagina

)

Vulva

After teaching a group of pregnant women about breast-feeding, the nurse

determines that the teaching was successful when the group identifies which

hormone as important for the production of breast milk after childbirth?

)

Placental estrogen

)

Progesterone

)

Gonadotropin-releasing hormone

)

Prolactin

The nurse is assessing a 13-year-old girl who has had her first menses. Which of

the following events would the nurse expect to have occurred first?

)

Evidence of pubic hair

)

Development of breast buds

)

Onset of menses

)

Growth spurt

When describing the ovarian cycle to a group of students, which phase would

the instructor include?

)

Luteal phase

)

Proliferative phase

)

Menstrual phase

)

Secretory phase

The nurse is explaining the events that lead up to ovulation. Which hormone

would the nurse identify as being primarily responsible for ovulation?

)

Estrogen

)

Progesterone

)

Follicle-stimulating hormone

)

Luteinizing hormone

)

Estrogen

)

Progesterone

)

Follicle-stimulating hormone

)

Luteinizing hormone

The nurse is teaching a health education class on male reproductive anatomy and

asks the students to identify the site of sperm production. Which structure, if

identified by the group, would indicate to the nurse that the teaching was

successful?

)

Testes

)

Seminal vesicles

)

Scrotum

)

Prostate gland

The nurse is creating a diagram that illustrates the components of the male

reproductive system. Which structure would be inappropriate for the nurse to

include as an accessory gland?

)

Seminal vesicles

)

Prostate gland

)

Cowpers glands

)

Vas deferens

The nurse is preparing an outline for a class on the physiology of the male

sexual response. Which event would the nurse identify as occurring first?

)

Sperm emission

)

Penile vasodilation

)

Psychological release

)

Ejaculation

A woman comes to the clinic complaining that she has little sexual desire. As

part of the clients evaluation, the nurse would anticipate the need to evaluate

which hormone level?

)

Progesterone

)

Estrogen

)

Gonadotropin-releasing hormone

)

Testosterone

A nurse is conducting a class for a group of teenage girls about female

reproductive anatomy and physiology. Which of the following would the nurse

include as an external female reproductive organ? Select all that apply.

)

Mons pubis

)

Labia

)

Vagina

Clitoris

reproductive anatomy and physiology. Which of the following would the nurse

include as an external female reproductive organ? Select all that apply.

)

Mons pubis

)

Labia

)

Vagina

)

Clitoris

)

Uterus

When describing the hormones involved in the menstrual cycle, a nurse

identifies which hormone as responsible for initiating the cycle?

)

Estrogen

)

Luteinizing hormone

)

Progesterone

)

Prolactin

A nursing instructor is describing the hormones involved in the menstrual cycle

to a group of nursing students. The instructor determines the teaching was

successful when the students identify follicle-stimulating hormone as being

secreted by which of the following?

)

Hypothalamus

)

Anterior pituitary gland

)

Ovaries

)

Corpus luteum

)

Hypothalamus

)

Anterior pituitary gland

)

Ovaries

)

Corpus luteum

A woman comes to the clinic for an evaluation. During the visit, the woman

tells the nurse that her menstrual cycles have become irregular. Ive also been

waking up at night feeling really hot and sweating. The nurse interprets these

findings as which of the following?

)

Menopause

)

Perimenopause

)

Climacteric

)

Menarche

After teaching a group of students about female reproductive anatomy, the

instructor determines that the teaching was successful when the students identify

which of the following as the site of fertilization?

)

Vagina

)

Uterus

)

Fallopian tubes

)

Vestibule

A woman comes to the clinic complaining of a vaginal discharge. The nurse

suspects that the client has an infection. When gathering additional information,

which of the following would the nurse be least likely to identify as placing the

client at risk for an infection?

)

Recent antibiotic therapy for an upper respiratory infection

)

Last menstrual period about 5 days ago.

)

Weekly douching

)

Frequent use of feminine hygiene sprays.

A group of nursing students are reviewing information about the male

reproductive structures. The students demonstrate understanding of the

information when they identify which of the following as accessory organs?

(Select all that apply.)

)

Testes

)

Vas deferens

)

Bulbourethral glands

)

Prostate gland

)

Penis

A nurse is examining a female client and tests the clients vaginal pH. Which

finding would the nurse interpret as normal?

)

4.5

)

8.5

)

When describing the male sexual response to a group of students, the instructor

determines that the teaching was successful when they identify emission as

which of the following?

)

Semen forced through the urethra to the outside

)

Movement of sperm from the testes and fluid into the urethras

)

Dilation of the penile arteries with increased blood flow to the tissues.

)

Bodys return to the physiologic nonstimulated state

A nurse is describing the structure and function of the reproductive system to an

adolescent health class. The nurse describes the secretion of the seminal vesicles

as which of the following?

)

Mucus-like

)

Alkaline

)

Acidic

Semen

adolescent health class. The nurse describes the secretion of the seminal vesicles

as which of the following?

)

Mucus-like

)

Alkaline

)

Acidic

)

Semen

Chapter 4 Common Reproductive Issues

After discussing various methods of contraception with a client and her partner,

the nurse determines that the teaching was successful when they identify which

contraceptive method as providing protection against sexually transmitted

infections (STIs)?

)

Oral contraceptives

)

Tubal ligation

)

Condoms

)

Intrauterine system

When discussing contraceptive options, which method would the nurse

recommend as being the most reliable?

)

Coitus interruptus

)

Lactational amenorrheal method (LAM)

)

Natural family planning

)

Intrauterine system

)

Coitus interruptus

)

Lactational amenorrheal method (LAM)

)

Natural family planning

)

Intrauterine system

A client comes to the clinic with abdominal pain. Based on her history the nurse

suspects endometriosis. The nurse expects to prepare the client for which of the

following to confirm this suspicion?

)

Pelvic examination

)

Transvaginal ultrasound

)

Laparoscopy

)

Hysterosalpingogram

A client is to receive an implantable contraceptive. The nurse describes this

contraceptive as containing:

)

Synthetic progestin

)

Combined estrogen and progestin

)

Concentrated spermicide

)

Concentrated estrogen

The nurse discusses various contraceptive methods with a client and her partner.

Which method would the nurse explain as being available only with a

prescription?

)

Condom

)

Spermicide

)

Diaphragm

)

Basal body temperature

When developing a teaching plan for a couple considering contraception options,

which of the following statements would the nurse include?

)

You should select one that is considered to be 100% effective.

)

The best one is the one that is the least expensive and most convenient.

)

A good contraceptive doesnt require a physicians prescription.

)

The best contraceptive is one that you will use correctly and consistently.

Which of the following measures would the nurse include in the teaching plan

for a woman to reduce the risk of osteoporosis after menopause?

)

Taking vitamin supplements

)

Eating high-fiber, high-calorie foods

)

Restricting fluid to 1,000 mL daily

)

Participating in regular daily exercise

)

Taking vitamin supplements

)

Eating high-fiber, high-calorie foods

)

Restricting fluid to 1,000 mL daily

)

Participating in regular daily exercise

When teaching a group of postmenopausal women about hot flashes and night

sweats, the nurse would address which of the following as the primary cause?

)

Poor dietary intake

)

Estrogen deficiency

)

Active lifestyle

)

Changes in vaginal pH

A client states that she is to have a test to measure bone mass to help diagnose

osteoporosis. The nurse would most likely plan to prepare the client for:

)

DEXA scan

)

Ultrasound

)

MRI

)

Pelvic x-ray

The nurse is reviewing the medical records of several clients. Which client

would the nurse expect to have an increased risk for developing osteoporosis?

)

A woman of African American descent

)

A woman who plays tennis twice a week

)

A thin woman with small bones

)

A woman who drinks one cup of coffee a day

Which of the following would the nurse emphasize when teaching

postmenopausal women about ways to reduce the risk of osteoporosis?

)

Swimming daily

)

Taking vitamin A

)

Following a low-fat diet

)

Taking calcium supplements

Which finding would the nurse expect to find in a client with endometriosis?

)

Hot flashes

)

Dysuria

)

Fluid retention

Fever

)

Hot flashes

)

Dysuria

)

Fluid retention

)

Fever

After the nurse teaches a client about ways to reduce the symptoms of

premenstrual syndrome, which client statement indicates a need for additional

teaching?

)

I will make sure to take my estrogen supplements a week before my period.

)

Ive signed up for an aerobic exercise class three times a week.

)

Ill cut down on the amount of coffee and colas I drink.

)

I quit smoking about a month ago, so that should help.

A woman has opted to use the basal body temperature method for contraception.

The nurse instructs the client that a rise in basal body temperature indicates

which of the following?

)

Onset of menses

)

Ovulation

)

Pregnancy

)

Safe period for intercourse

)

Ovulation

)

Pregnancy

)

Safe period for intercourse

A woman using the cervical mucus ovulation method of fertility awareness

reports that her cervical mucus looks like egg whites. The nurse interprets this

as which of the following?

)

Spinnbarkeit mucus

)

Purulent mucus

)

Postovulatory mucus

)

Normal preovulation mucus

The nurse is reviewing the laboratory test results of a client with dysfunctional

uterine bleeding (DUB). Which finding would be of concern?

)

Negative pregnancy test

)

Hemoglobin level of 10.1 g/dL

)

Prothrombin time of 60 seconds

)

Serum cholesterol of 140 mg/dL

A nurse is preparing a class for a group of women at a family planning clinic

about contraceptives. When describing the health benefits of oral contraceptives,

which of the following would the nurse most likely include? (Select all that

apply.)

)

Protection against pelvic inflammatory disease

)

Reduced risk for endometrial cancer

)

Decreased risk for depression

)

Reduced risk for migraine headaches

)

Improvement in acne

After teaching a group of students about the different methods for

contraception, the instructor determines that the teaching was successful when

the students identify which of the following as a mechanical barrier method?

(Select all that apply.)

)

Condom

)

Cervical cap

)

Cervical sponge

)

Diaphragm

)

Vaginal ring

After assessing a woman who has come to the clinic, the nurse suspects that the

woman is experiencing dysfunctional uterine bleeding. Which statement by the

client would support the nurses suspicions?

)

Ive been having bleeding off and on thats irregular and sometimes heavy.

)

I get sharp pain in my lower abdomen usually starting soon after my period

comes.

)

I get really irritable and moody about a week before my period.

)

My periods have been unusually long and heavy lately.

After teaching a group of students about premenstrual syndrome, the instructor

determines that additional teaching is needed when the students identify which

of the following as a prominent assessment finding?

)

Bloating

)

Tension

)

Dysphoria

)

Weight loss

A nurse is describing the criteria needed for the diagnosis of premenstrual

dysphoric disorder (PMDD). Which of the following would the nurse include as

a mandatory requirement for the diagnosis?

)

Appetite changes

)

Sleep difficulties

)

Persistent anger

Chronic fatigue

dysphoric disorder (PMDD). Which of the following would the nurse include as

a mandatory requirement for the diagnosis?

)

Appetite changes

)

Sleep difficulties

)

Persistent anger

)

Chronic fatigue

When reviewing the medical record of a client diagnosed with endometriosis,

which of the following would the nurse identify as a risk factor for this woman?

)

Low fat in the diet

)

Age of 14 years for menarche

)

Menstrual cycles of 24 days

)

Short menstrual flow

A client who has come to the clinic is diagnosed with endometriosis. Which of

the following would the nurse expect the physician to prescribe as a first-line

treatment?

)

Progestins

)

Antiestrogens

)

Gonadotropin-releasing hormone analogues

)

NSAIDs

)

Antiestrogens

)

Gonadotropin-releasing hormone analogues

)

NSAIDs

A woman comes to the clinic because she has been unable to conceive. When

reviewing the womans history, which of the following would the nurse least

likely identify as a possible risk factor?

)

Age of 25 years

)

History of smoking

)

Diabetes since age 15 years

)

Weight below standard for height and age

A couple comes to the clinic for a fertility evaluation. The male partner is to

undergo a semen analysis. After teaching the partner about this test, which

client statement indicates that the client has understood the instructions?

)

I need to bring the specimen to the lab the day after collecting it.

)

I will place the specimen in a special plastic bag to transport it.

)

I have to abstain from sexual activity for about 12 days before the sample.

)

I will withdraw before I ejaculate during sex to collect the specimen.

A nurse is preparing a class for a group of young adult women about emergency

contraceptives (ECs). Which of the following would the nurse need to stress to

the group. Select all that apply.

)

ECs induce an abortion like reaction.

)

ECs provide some protection against STIs

A nurse is preparing a class for a group of young adult women about emergency

contraceptives (ECs). Which of the following would the nurse need to stress to

the group. Select all that apply.

)

ECs induce an abortion like reaction.

)

ECs provide some protection against STIs

)

ECs are birth control pills in higher, more frequent doses

)

ECs are not to be used in place of regular birth control

)

ECs provide little protection for future pregnancies.

Chapter 5 Sexually Transmitted Infections

The nurse is developing a plan of care for a client who is receiving highly active

antiretroviral therapy (HAART) for treatment of HIV. The goal of this therapy is

to:

)

Promote the progression of disease

)

Intervene in late-stage AIDS

)

Improve survival rates

)

Conduct additional drug research

A woman who is HIV-positive is receiving HAART and is having difficulty with

compliance. To promote adherence, which of the following areas would be most

important to assess initially?

)

The womans beliefs and education

)

The womans financial situation and insurance

)

The womans activity level and nutrition

)

The womans family and living arrangements

When developing a teaching plan for a community group about HIV infection,

which group would the nurse identify as an emerging risk group for HIV

infection?

)

Native Americans

)

Heterosexual women

)

New health care workers

)

Asian immigrants

After teaching a group of adolescents about HIV, the nurse asks them to identify

the major means by which adolescents are exposed to the virus. The nurse

determines that the teaching was successful when the group identifies which of

the following?

)

Sexual intercourse

)

Sharing needles for IV drug use

)

Perinatal transmission

determines that the teaching was successful when the group identifies which of

the following?

)

Sexual intercourse

)

Sharing needles for IV drug use

)

Perinatal transmission

)

Blood transfusion

The nurse reviews the CD4 cell count of a client who is HIV-positive. A result

less than which of the following would indicate to the nurse that the client has

AIDS?

)

1,000 cells/mm3

)

700 cells/mm3

)

450 cells/mm3

)

200 cells/mm3

When obtaining the health history from a client, which factor would lead the

nurse to suspect that the client has an increased risk for sexually transmitted

infections (STIs)?

)

Hive-like rash for the past 2 days

)

Five different sexual partners

)

Weight gain of 5 lbs in 1 year

)

Clear vaginal discharge

)

Five different sexual partners

)

Weight gain of 5 lbs in 1 year

)

Clear vaginal discharge

Assessment of a female client reveals a thick, white vaginal discharge. She also

reports intense itching and dyspareunia. Based on these findings, the nurse

would suspect that the client has:

)

Trichomoniasis

)

Bacterial vaginosis

)

Candidiasis

)

Genital herpes simplex

A client with trichomoniasis is to receive metronidazole (Flagyl). The nurse

instructs the client to avoid which of the following while taking this drug?

)

Alcohol

)

Nicotine

)

Chocolate

)

Caffeine

A woman gives birth to a healthy newborn. As part of the newborns care, the

nurse instills erythromycin ophthalmic ointment as a preventive measure related

to which STI?

)

Genital herpes

)

Hepatitis B

Syphilis

A woman gives birth to a healthy newborn. As part of the newborns care, the

nurse instills erythromycin ophthalmic ointment as a preventive measure related

to which STI?

)

Genital herpes

)

Hepatitis B

)

Syphilis

)

Gonorrhea

Which findings would the nurse expect to find in a client with bacterial

vaginosis?

)

Vaginal pH of 3

)

Fish-like odor of discharge

)

Yellowish-green discharge

)

Cervical bleeding on contact

A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The

nurse discusses the risk of transmitting the infection to her newborn, explaining

that this infection is transmitted to the newborn through the:

)

Amniotic fluid

)

Placenta

)

Birth canal

)

Breast milk

)

Amniotic fluid

)

Placenta

)

Birth canal

)

Breast milk

The nurse encourages a female client with human papillomavirus (HPV) to

receive continued follow-up care because she is at risk for:

)

Infertility

)

Dyspareunia

)

Cervical cancer

)

Dysmenorrhea

A client is diagnosed with pelvic inflammatory disease (PID). When reviewing

the clients medical record, which of the following would the nurse expect to

find? (Select all that apply.)

)

Oral temperature of 100.4 degrees F

)

Dysmenorrhea

)

Dysuria

)

Lower abdominal tenderness

)

Discomfort with cervical motion

)

Multiparity

)

Dysuria

)

Lower abdominal tenderness

)

Discomfort with cervical motion

)

Multiparity

Which instructions would the nurse include when teaching a woman with

pediculosis pubis?

)

Take the antibiotic until you feel better.

)

Wash your bed linens in bleach and cold water.

)

Your partner doesnt need treatment at this time.

)

Remove the nits with a fine-toothed comb.

A client with genital herpes simplex infection asks the nurse, Will I ever be

cured of this infection? Which response by the nurse would be most

appropriate?

)

There is a new vaccine available that prevents the infection from returning.

)

All you need is a dose of penicillin and the infection will be gone.

)

There is no cure, but drug therapy helps to reduce symptoms and recurrences.

)

Once you have the infection, you develop an immunity to it.

A nurse is preparing a presentation for a group of women at the clinic who have

been diagnosed with genital herpes. Which of the following would the nurse

expect to include as a possible precipitating factor for a recurrent outbreak?

(Select all that apply.)

)

Exposure to ultraviolet light

)

Exercise

)

Use of corticosteroids

)

Emotional stress

)

Sexual intercourse.

After teaching a class on sexually transmitted infections, the instructor

determines that the teaching was successful when the class identifies which

statement as true?

)

STIs can affect anyone if exposed to the infectious organism.

)

STIs have been addressed more on a global scale.

)

Clients readily view the diagnosis of STI openly.

)

Most individuals with STIs are over the age of 30.

A group of students are reviewing information about STIs. The students

demonstrate understanding of the information when they identify which of the

following as the most common bacterial STI in the United States?

)

Gonorrhea

)

Chlamydia

A group of students are reviewing information about STIs. The students

demonstrate understanding of the information when they identify which of the

following as the most common bacterial STI in the United States?

)

Gonorrhea

)

Chlamydia

)

Syphilis

)

Candidiasis

A nurse is assessing a client for possible risk factors for chlamydia and

gonorrhea. Which of the following would the nurse identify?

)

Asian American ethnicity

)

Age under 25 years

)

Married

)

Consistent use of barrier contraception

A nurse at a local community clinic is developing a program to address STI

prevention. Which of the following would the nurse least likely include in the

program?

)

Outlining safer sexual behavior

)

Recommending screening for symptomatic individuals

)

Promoting the use of barrier contraceptives

)

Offering education about STI transmission

)

Outlining safer sexual behavior

)

Recommending screening for symptomatic individuals

)

Promoting the use of barrier contraceptives

)

Offering education about STI transmission

After teaching a class on preventing pelvic inflammatory disease, the instructor

determines that the teaching was successful when the class identifies which of

the following as an effective method?

)

Advising sexually active females to use hormonal contraception

)

Encouraging vaginal douching on a weekly basis.

)

Emphasizing the need for infected sexual partners to receive treatment

)

Promoting routine treatment for asymptomatic females as risk

A group of nursing students are reviewing information about vaccines used to

prevent STIs. The students would expect to find information about which of the

following?

)

HIV

)

HSV

)

HPV

)

HAV

)

HBV

)

HPV

)

HAV

)

HBV

A mother brings her 12-year-old daughter in for well-visit checkup. During the

visit, the nurse is discussing the use of prophylactic HPV vaccine for the

daughter. The mother agrees and the daughter receives her first dose. The nurse

schedules the daughter for the next dose, which would be given at which time?

)

In 2 month

)

In 2 months

)

In 3 months

)

In 4 months

A woman comes to the clinic complaining of a vaginal discharge. The nurse

suspects trichomoniasis based on which of the following? (Select all that apply.)

)

Urinary frequency

)

Yellow/green discharge

)

Joint pain

)

Blister-like lesions

)

Muscle aches

A nurse is teaching a women with genital ulcers how to care for them. Which

statement by the client indicates a need for additional teaching?

)

I need to wash my hands after touching any of the ulcers.

)

I need to abstain from intercourse primarily when the lesions are present.

)

I should avoid applying ice or heat to my genital area.

)

I can try lukewarm sitz baths to help ease the discomfort.

Chapter 6 Disorders of the Breasts

The nurse is developing the discharge plan for a woman who has had a left-sided

modified radical mastectomy. The nurse is including instructions for ways to

minimize lymphedema. Which suggestion would most likely increase the

womans symptoms?

)

Wear gloves when you are doing any gardening.

)

Have your blood pressure taken in your right arm.

)

Wear clothing with elasticized sleeves.

)

Avoid driving to and from work every day.

)

Have your blood pressure taken in your right arm.

)

Wear clothing with elasticized sleeves.

)

Avoid driving to and from work every day.

A laboratory technician arrives to draw blood for a complete blood count (CBC.

for a client who had a right-sided mastectomy 8 hours ago. The client has an

intravenous line with fluid infusing in her left antecubital space. To obtain the

blood specimen, the technician places a tourniquet on the clients right arm.

Which action by the nurse would be most appropriate?

)

Assist in holding the clients arm still.

)

Suggest a finger stick be done on one of the clients left fingers.

)

Tell the technician to obtain the blood sample from the clients left arm.

)

Call the surgeon to perform a femoral puncture.

The nurse determines that a woman has implemented prescribed therapy for her

fibrocystic breast disease when the client reports that she has eliminated what

from her diet?

)

Caffeine

)

Cigarettes

)

Dairy products

)

Sweets

When assessing a client with suspected breast cancer, which of the following

would the nurse expect to find?

)

Painful lump

)

Absence of dimpling

)

Regularly shaped mass

)

Nipple retraction

A woman who has undergone a right modified-radical mastectomy returns from

surgery. Which nursing intervention would be most appropriate at this time?

)

Ask the client how she feels about having her breast removed.

)

Attach a sign above her bed to have BP, IV lines, and lab work in her right arm.

)

Encourage her to turn, cough, and deep breathe at frequent intervals.

)

Position her right arm below heart level.

A breast biopsy indicates the presence of malignant cells, and the client is

scheduled for a mastectomy. Which nursing diagnosis would the nurse most

likely include in the clients preoperative plan of care as the priority?

)

Risk for deficient fluid volume

)

Activity intolerance

)

Disturbed body image

)

Impaired urinary elimination

)

Risk for deficient fluid volume

)

Activity intolerance

)

Disturbed body image

)

Impaired urinary elimination

A 42-year-old woman is scheduled for a mammogram. Which of the following

would the nurse include when teaching the woman about the procedure?

)

The room will be darkened throughout the procedure.

)

Each breast will be firmly compressed between two plates.

)

Make sure to refrain from eating or drinking after midnight.

)

A small needle will be inserted to get a sample for evaluation.

During a clinical breast examination, the nurse palpates a well-defined, firm,

mobile lump in a 60-year-old womans left breast. The nurse notifies the

physician. Which of the following would the nurse anticipate the physician to

order next?

)

Mammogram

)

Hormone receptor status

)

Fine-needle aspiration

)

Genetic testing for BRCA

A client with advanced breast cancer, who has had both chemotherapy and

radiation therapy, is to start hormonal therapy. Which agent would the nurse

expect the client to receive?

)

Progestins

)

Tamoxifen

)

Cortisone

)

Estrogen

As part of discharge planning, the nurse refers a woman to Reach to Recovery.

This groups primary purpose is to:

)

Help support women who have undergone mastectomies

)

Raise funds to support early breast cancer detection programs

)

Provide all supplies needed after breast surgery for no cost

)

Collect statistics for research for the American Cancer Society

A woman with breast cancer is undergoing chemotherapy. Which of the

following side effects would the nurse interpret as being most serious?

)

Vomiting

)

Hair loss

)

Fatigue

Myelosuppression

following side effects would the nurse interpret as being most serious?

)

Vomiting

)

Hair loss

)

Fatigue

)

Myelosuppression

A woman comes to the clinic reporting a nipple discharge. On examination, the

area below the areola is red and slightly swollen, with tortuous tubular swelling.

The nurse interprets these findings as suggestive of which of the following?

)

Fibrocystic breast disorder

)

Intraductal papilloma

)

Duct ectasia

)

Fibroadenoma

When performing a clinical breast examination, which would the nurse do

first?

)

Palpate the axillary area.

)

Compress the nipple for a discharge.

)

Palpate the breasts.

)

Inspect the breasts.

)

Compress the nipple for a discharge.

)

Palpate the breasts.

)

Inspect the breasts.

Evaluation of a woman with breast cancer reveals that her mass is

approximately 1.25 inches in diameter. Three adjacent lymph nodes are

positive. The nurse interprets this as indicating that the woman has which stage

of breast cancer?

)

III

After teaching a woman how to perform breast self-examination, which

statement would indicate that the nurses instructions were successful?

)

I should lie down with my arms at my side when looking at my breasts.

)

I should use the fingerpads of my three middle fingers to apply pressure to my

breast.

)

I dont need to check under my arm on that side if my breast feels fine.

)

I need to work from the center of my breast outward toward my shoulder.

A nurse is working with a woman who has been diagnosed with severe

fibrocystic breast disease. When describing the medications that can be used as

treatment, which of the following would the nurse be least likely to include?

)

Tamoxifen

)

Bromocriptine

)

Danazol

)

Penicillin

A group of students are reviewing information about benign and malignant

breast masses. The students demonstrate understanding when they identify

which of the following as indicating a benign breast mass. (Select all the apply.)

)

Painless

)

Unilateral location

)

Firm consistency

)

Absence of dimpling

)

Fixed to chest wall

The nurse is developing a plan of care for a woman with breast cancer who is

scheduled to undergo breast-conserving surgery. The nurse interprets this as

which of the following?

)

Removal of nipple and areolar area

)

Lump removal followed by radiation

Entire breast removal without lymph nodes

The nurse is developing a plan of care for a woman with breast cancer who is

scheduled to undergo breast-conserving surgery. The nurse interprets this as

which of the following?

)

Removal of nipple and areolar area

)

Lump removal followed by radiation

)

Entire breast removal without lymph nodes

)

Axillary lymph node removal

A woman comes to the clinic and asks the nurse about when she should have

her first mammogram. Using the recommendations of the American Cancer

Society, which would the nurse suggest?

)

30 years

)

35 years

)

40 years

)

45 years

After teaching a group of nursing students about the different types of

chemotherapeutic agents used to treat breast cancer, the instructor determines

that the teaching was successful when the students identify which of the

following as an example of a selective estrogen receptor modulator (SERM)?

(Select all that apply.)

)

Tamoxifen

)

Letozole

)

Raloxifene

)

Exemestane

)

Tamoxifen

)

Letozole

)

Raloxifene

)

Exemestane

)

Anastrozole

A woman diagnosed with breast cancer is to receive trastuzumab. Which of the

following would the nurse incorporate into the explanation about how this drug

works?

)

It blocks the effect of the HER-2/neu protein inhibiting the growth of cancer

cells.

)

The drug blocks the conversion of androgens to estrogens

)

It interferes with hormone receptors that allow estrogen to enter a cell

)

The drug ultimately attacks areas where micrometastasis has occurred.

A nurse is conducting a class on breast cancer prevention. Which statement

would the nurse most likely include in the discussion?

)

Most often a lump is felt before it is seen.

)

Early breast cancer usually has some symptoms.

)

If the mass is not painful, it is usually benign.

)

If lump is palpable, it has been there for some time.

)

Early breast cancer usually has some symptoms.

)

If the mass is not painful, it is usually benign.

)

If lump is palpable, it has been there for some time.

When describing programs for breast cancer screening, the nurse include breast

self-examination (BSE). Which of the following most accurately reflects the

current thinking about breast self-examination?

)

BSE is essential for early breast cancer detection.

)

A woman performing BSE has breast awareness.

)

BSE plays a minimal role in detecting breast cancer

)

A clinical breast exam has replaced BSE.

During a wellness visit to the clinic, a woman asks the nurse if there is anything

she can do to reduce her risk for developing breast cancer. Which of the

following would the nurse most likely include? (Select all that apply.)

)

Eating three servings of fruit daily

)

Keeping weight gain under 11 pounds after age 18

)

Eating at least seven portions of complex carbohydrates daily

)

Limiting the intake of refined sugar products

)

Using salt liberally when cooking

A woman comes to the clinic and tells the nurse that she has read an article

about certain foods that have anticancer properties and help boost the immune

system. The nurse identifies

)

Garlic

)

Soybeans

)

Milk

)

Leeks

)

Flax seeds

Chapter 7 Benign Disorders of the Female Reproductive Tract

A woman is admitted for repair of cystocele and rectocele. She has nine living

children. In taking her health history, which of the following would the nurse

expect to find?

)

Sporadic vaginal bleeding accompanied by chronic pelvic pain

)

Heavy leukorrhea with vulvar pruritus

)

Menstrual irregularities and hirsutism on the chin

)

Stress incontinence with feeling of low abdominal pressure

)

Heavy leukorrhea with vulvar pruritus

)

Menstrual irregularities and hirsutism on the chin

)

Stress incontinence with feeling of low abdominal pressure

To assist the woman in regaining control of the urinary sphincter for urinary

incontinence, the nurse should teach the client to do which of the following?

)

Perform Kegel exercises daily.

)

Void every hour while awake.

)

Limit her intake of fluid.

)

Take a laxative every night.

When developing the plan of care for a woman who has had an abdominal

hysterectomy, which of the following would be contraindicated?

)

Ambulating the client

)

Massaging the clients legs

)

Applying elasticized stockings

)

Encouraging range-of-motion exercises

Which of the following would the nurse include when teaching women about

preventing pelvic support disorders?

)

Performing Kegel isometric exercises

)

Consuming low-fiber diets

)

Using hormone replacement

Which of the following would the nurse include when teaching women about

preventing pelvic support disorders?

)

Performing Kegel isometric exercises

)

Consuming low-fiber diets

)

Using hormone replacement

)

Voiding every 2 hours

A client is diagnosed with an enterocele. The nurse interprets this condition as:

)

Protrusion of the posterior bladder wall downward through the anterior vaginal

wall

)

Sagging of the rectum with pressure exerted against the posterior vaginal wall

)

Bulging of the small intestine through the posterior vaginal wall

)

Descent of the uterus through the pelvic floor into the vagina

A woman is scheduled for an anterior and posterior colporrhaphy as treatment

for a cystocele. When the nurse is explaining this treatment to the client, which

of the following descriptions would be most appropriate to include?

)

This procedure helps to tighten the vaginal wall in the front and back so that

your bladder and urethra are in the proper position.

)

Your uterus will be removed through your vagina, helping to relieve the organ

that is putting the pressure on your bladder.

)

This is a series of exercises that you will learn to do so that you can strengthen

your bladder muscles.

)

These are plastic devices that your physician will insert into your vagina to

provide support to the uterus and keep it in the proper position.

The nurse would be least likely to find which of the following in a client with

uterine fibroids?

)

Regularly shaped, shrunken uterus

)

Acute pelvic pain

)

Menorrhagia

)

Complaints of bloating

A client with polycystic ovarian syndrome (PCOS. is receiving oral

contraceptives as part of her treatment plan. The nurse understands that the

rationale for this therapy is to:

)

Restore menstrual regularity

)

Induce ovulation

)

Improve insulin uptake

)

Alleviate hirsutism

When teaching a woman how to perform Kegel exercises, the nurse explains that

these exercises are designed to strengthen which muscles?

)

Gluteus

)

Lower abdominal

)

Pelvic floor

)

Diaphragmatic

)

Gluteus

)

Lower abdominal

)

Pelvic floor

)

Diaphragmatic

A postmenopausal woman with uterine prolapse is being fitted with a pessary.

The nurse would be most alert for which side effect?

)

Increased vaginal discharge

)

Urinary tract infection

)

Vaginitis

)

Vaginal ulceration

When preparing the discharge teaching plan for the woman who had surgery to

correct pelvic organ prolapse, which of the following would the nurse include?

)

Care of the indwelling catheter at home

)

Emphasis on coughing to prevent complications

)

Return to usual activity level in a few days

)

Daily douching with dilute vinegar solution

A woman with polycystic ovary syndrome tells the nurse, I hate this disease.

Just look at me! I have no hair on the front of my head but Ive got hair on my

chin and upper lip. I dont feel like a woman anymore. Further assessment

reveals breast atrophy and increased muscle mass. Which nursing diagnosis

would most likely be a priority?

)

Situational low self-esteem related to masculinization effects of the disease

)

Social isolation related to feelings about appearance

)

Risk for suicide related to effects of condition and fluctuating hormone levels

)

Ineffective peripheral tissue perfusion related to effects of disease on

vasculature

After teaching a local womans group about incontinence, the nurse determines

that the teaching was successful when the group identifies which of the

following as characteristic of stress incontinence?

)

Feeling a strong need to void

)

Passing a large amount of urine

)

Most common in women after childbirth

)

Sneezing may be an initiating stimulus

A woman is being evaluated for pelvic organ prolapse. A postvoid residual

urine specimen is obtained via a catheter. Which residual volume finding would

lead the nurse to suspect the need for further testing?

)

50 mL

)

75 mL

100 mL

A woman is being evaluated for pelvic organ prolapse. A postvoid residual

urine specimen is obtained via a catheter. Which residual volume finding would

lead the nurse to suspect the need for further testing?

)

50 mL

)

75 mL

)

100 mL

)

120 mL

After teaching a woman with pelvic organ prolapse about dietary and lifestyle

measures, which of the following statements would indicate the need for

additional teaching?

)

If I wear a girdle, it will help support the muscles in the area.

)

I should take up jogging to make sure I exercise enough.

)

I will try to drink at least 64 oz of fluid each day.

)

I need to increase the amount of fiber I eat every day.

After teaching a group of students about genital fistulas, the instructor

determines that the teaching was successful when the students identify which of

the following as a major cause?

)

Radiation therapy

)

Congenital anomaly

)

Female genital cutting

)

Bartholins gland abscess

)

Radiation therapy

)

Congenital anomaly

)

Female genital cutting

)

Bartholins gland abscess

A nurse is providing care to a female client receiving treatment for a Bartholins

cyst. The client has had a small loop of plastic tubing secured in place to allow

for drainage. The nurse instructs the client that she will have a follow-up

appointment for removal of the plastic tubing at which time?

)

1 week

)

2 weeks

)

3 weeks

)

4 weeks

After undergoing diagnostic testing, a woman is diagnosed with a corpus luteum

cyst. The nurse anticipates that the woman will require:

)

Biopsy

)

No treatment

)

Oral contraceptives

)

Glucophage

A nurse is teaching a client how to perform Kegel exercises. Which of the

following would the nurse include? (Select all that apply.)

)

Squeeze your rectal muscles as if you are trying to avoid passing flatus.

)

Tighten your pubococcygeal muscles for a count of 10.

)

Contract and relax your pubococcygeal muscles rapidly 10 times.

)

Try bearing down for about 10 seconds for no more than 5 times.

)

Do these exercises at least 5 times every hour.

After teaching a group of students about pelvic organ prolapse, the instructor

determines that the teaching was successful when the group identifies

leiomyomas as which of the following?

)

Cysts

)

Pelvic organ prolapse

)

Fistula

)

Fibroid

A nurse is assessing a female client and suspects that the client may have

endometrial polyps based on which of the following?

)

Bleeding after intercourse

)

Vaginal discharge

Bleeding between menses

A nurse is assessing a female client and suspects that the client may have

endometrial polyps based on which of the following?

)

Bleeding after intercourse

)

Vaginal discharge

)

Bleeding between menses

)

Metrorrhagia

After teaching a group of students about ovarian cysts, the instructor determines

that the teaching was successful when the students identify which type of cyst as

being associated with hydatiform mole?

)

Theca-lutein cyst

)

Corpus luteum cyst

)

Follicular cyst

)

Polycystic ovarian syndrome

A nurse is reading a journal article about care of the woman with pelvic organ

prolapse. The nurse would expect to find information related to which of the

following? (Select all that apply.)

)

Rectocele

)

Fecal incontinence

)

Cystocele

)

Urinary incontinence

)

Enterocele

)

Rectocele

)

Fecal incontinence

)

Cystocele

)

Urinary incontinence

)

Enterocele

A nurse is reviewing the medical record of a client. Which of the following

would lead the nurse to suspect that the client is experiencing polycystic ovarian

syndrome? (Select all that apply..

)

Decreased androgen levels

)

Elevated blood insulin levels

)

Anovulation

)

Waist circumference of 32 inches

)

Triglyceride level of 175 mg/dL

)

High-density lipoprotein level of 40 mg/dL

A group of students are preparing a class presentation about polyps. Which of

the following would the students most likely include in the presentation?

)

Polyps are rarely the result of an infection.

)

Endocervical polyps commonly appear after menarche.

)

Cervical polyps are more common than endocervical polyps.

)

Endocervical polyps are most common in women in their 50s.

the following would the students most likely include in the presentation?

)

Polyps are rarely the result of an infection.

)

Endocervical polyps commonly appear after menarche.

)

Cervical polyps are more common than endocervical polyps.

)

Endocervical polyps are most common in women in their 50s.

Chapter 8 Cancers of the Female Reproductive Tract

The nurse would refer a client, age 54, for follow-up for suspected endometrial

carcinoma if she reports which of the following?

)

Use of oral contraceptives between ages 18 and 25

)

Onset of painless, red postmenopausal bleeding

)

Menopause occurring at age 46

)

Use of intrauterine device for 3 years

Which of the following instructions would the nurse include when preparing a

woman for a Pap smear?

)

Refrain from sexual intercourse for 1 week before the test.

)

Wear cotton panties on the day of the test.

)

Avoid taking any medications for 24 hours.

Do not douche for 48 hours before the test.

Which of the following instructions would the nurse include when preparing a

woman for a Pap smear?

)

Refrain from sexual intercourse for 1 week before the test.

)

Wear cotton panties on the day of the test.

)

Avoid taking any medications for 24 hours.

)

Do not douche for 48 hours before the test.

A woman comes to the clinic for a routine checkup. A history of exposure to

which of the following would alert the nurse that she is at increased risk for

cervical cancer?

)

Hepatitis

)

Human papillomavirus

)

Cytomegalovirus

)

Epstein-Barr virus

A client is scheduled to have a Pap smear. After the nurse teaches the client

about the Pap smear, which of the following client statements indicates

successful teaching?

)

I need to douche the night before with a mild vinegar solution.

)

I will take a bath first thing that morning to make sure Im clean.

)

I will not engage in sexual intercourse for 48 hours before the test.

)

I will get a clean urine specimen when I first wake up the morning of the test.

)

I will take a bath first thing that morning to make sure Im clean.

)

I will not engage in sexual intercourse for 48 hours before the test.

)

I will get a clean urine specimen when I first wake up the morning of the test.

Which finding obtained during a client history would the nurse identify as

increasing a clients risk for ovarian cancer?

)

Multiple sexual partners

)

Consumption of a high-fat diet

)

Underweight

)

Grand multiparity (more than five children)

A client is scheduled for cryosurgery to remove some abnormal tissue on the

cervix. The nurse teaches the client about this treatment, explaining that the

tissue will be removed by which method?

)

Freezing

)

Cutting

)

Burning

)

Irradiating

Which of the following statements best indicates that a client has taken self-care

measures to reduce her risk for cervical cancer?

)

Ive really cut down on the amount of caffeine I drink every day.

)

Ive thrown out all my bubble baths and just use soap and water now.

)

Every time I have sexual intercourse, I douche.

Which of the following statements best indicates that a client has taken self-care

measures to reduce her risk for cervical cancer?

)

Ive really cut down on the amount of caffeine I drink every day.

)

Ive thrown out all my bubble baths and just use soap and water now.

)

Every time I have sexual intercourse, I douche.

)

My partner always uses a condom when we have sexual intercourse.

A client is suspected of having endometrial cancer. The nurse would most likely

prepare the client for which procedure to confirm the diagnosis?

)

Transvaginal ultrasound

)

Colposcopy

)

Pap smear

)

Endometrial biopsy

Which of the following descriptions would the nurse include when teaching a

client about her scheduled colposcopy?

)

A gel will be applied to your abdomen and a microphone-like device will be

moved over the area to identify problem areas.

)

A solution will be wiped on your cervix to identify any abnormal cells, which

will be visualized with a magnifying instrument.

)

Scrapings of tissue will be obtained and placed on slides to be examined under

the microscope.

)

After you receive anesthesia, a small device will be inserted into your abdomen

near your belly button to obtain tissue samples.

)

A solution will be wiped on your cervix to identify any abnormal cells, which

will be visualized with a magnifying instrument.

)

Scrapings of tissue will be obtained and placed on slides to be examined under

the microscope.

)

After you receive anesthesia, a small device will be inserted into your abdomen

near your belly button to obtain tissue samples.

The nurse is preparing a presentation for a local womens group about ways to

reduce the risk of reproductive tract cancers. Which of the following would the

nurse include?

)

Blood pressure evaluation every 6 months

)

Yearly Pap smears starting at age 40

)

Yearly cholesterol screening starting at age 45

)

Consumption of two to three glasses of red wine per day

The daughter of a woman who has been diagnosed with ovarian cancer asks the

nurse about screening for this cancer. Which response by the nurse would be

most appropriate?

)

Currently there is no reliable screening test for ovarian cancer.

)

A Pap smear is almost always helpful in identifying this type of cancer.

)

Theres a blood test for a marker, CA-125, that if elevated indicates cancer.

)

A genetic test for two genes, if positive, will identify the ovarian cancer.

Which of the following would the nurse be least likely to suggest when teaching

a group of young women how to reduce their risk for ovarian cancer?

)

Pregnancy

)

Oral contraceptives

Which of the following would the nurse be least likely to suggest when teaching

a group of young women how to reduce their risk for ovarian cancer?

)

Pregnancy

)

Oral contraceptives

)

Feminine hygiene sprays

)

Breast-feeding

A woman is diagnosed with adenocarcinoma of the endometrium in situ. The

nurse interprets this as indicating which of the following about the cancer?

)

Spread to the uterine muscle wall

)

Found on the endometrial surface

)

Spread to the cervix

)

Invaded the bladder

When preparing a woman with suspected vulvar cancer for a biopsy, the nurse

expects that the lesion would most likely be located at which area?

)

Labia majora

)

Labia minora

)

Clitoris

)

Prepuce

)

Labia majora

)

Labia minora

)

Clitoris

)

Prepuce

When describing the various types of reproductive tract cancers to a local

womens group, which of the following would the nurse identify as the least

common type?

)

Vulvar

)

Vaginal

)

Endometrial

)

Ovarian

When assessing a female client for the possibility of vulvar cancer, which of the

following would the nurse most likely expect the client to report? (Select all that

apply.)

)

Abnormal vaginal bleeding

)

Persistent vulvar itching

)

History of herpes simplex

)

Lesion on the cervix

)

Abnormal Pap smear

)

History of herpes simplex

)

Lesion on the cervix

)

Abnormal Pap smear

A nurse is reviewing the medical record of a woman diagnosed with vulvar

cancer. Which of the following would the nurse identify as a risk factor for this

cancer? (Select all that apply.)

)

Age under 40 years

)

HPV 16 exposure

)

Monogamous sexual partner

)

Hypertension

)

Diabetes

A nurse is assisting with the collection of a Pap smear. When collecting the

specimen, which of the following is done first?

)

Insertion of the speculum

)

Swabbing of the endocervix

)

Spreading of the labia

)

Insertion of the cytobrush

The plan of care for a woman diagnosed with a suspected reproductive cancer

includes a nursing diagnosis of disturbed body image related to suspected

reproductive tract cancer and impact on sexuality as evidenced by the clients

statement that she is worried that she wont be the same. Which of the following

would be an appropriate outcome for this client?

)

Client will verbalize positive statements about self and sexuality.

)

Client will demonstrate understanding of the condition and associated treatment.

)

Client will exhibit positive coping strategies related to diagnosis.

)

Client will identify misconceptions related to her diagnosis.

During a routine health check-up, a young adult woman asks the nurse about

ways to prevent endometrial cancer. Which of the following would the nurse

most likely include? (Select all that apply.)

)

Eating a high-fat diet

)

Having regular pelvic exams

)

Engaging in daily exercise

)

Becoming pregnant

)

Using estrogen contraceptives

After teaching a group of students about cervical cancer, the instructor

determines that the teaching was successful when the students identify which of

the following as the area included with a cone biopsy?

)

Clitoris

)

Uterine fundus

)

Ovarian follicle

)

Transformation zone

A woman is scheduled for diagnostic testing to evaluate for endometrial cancer.

The nurse would expect to prepare the woman for which of the following?

)

CA-125 testing

)

Transvaginal ultrasound

)

Pap smear

)

Mammography

A nurse is conducting a class for a local womans group about recommendations

for a Pap smear. One of the participants asks, At what age should a woman have

her first Pap smear? The nurse responds by stating that a woman should have

her first Pap smear at which age?

)

her first Pap smear? The nurse responds by stating that a woman should have

her first Pap smear at which age?

)

An instructor is describing the development of cervical cancer to a group of

students. The instructor determines that the teaching was successful when the

students identify which area as most commonly involved?

)

Internal cervical os

)

Junction of the cervix and fundus

)

Squamous-columnar junction

)

External cervical os

A client has an abnormal Pap smear that is classified as ASC-US. Based on the

nurses understanding of this classification, the nurse would expect which of the

following?

)

Immediate colposcopy

)

Testing for HPV

)

Repeat Pap smear in 4 to 6 months

)

Cone biopsy

)

Testing for HPV

)

Repeat Pap smear in 4 to 6 months

)

Cone biopsy

Chapter 9 Violence and Abuse

The nurse is presenting a class at a local community health center on violence

during pregnancy. Which of the following would the nurse include as a possible

complication?

)

Hypertension of pregnancy

)

Chorioamnionitis

)

Placenta previa

)

Postterm labor

Which approach would be most appropriate when counseling a woman who is a

suspected victim of violence?

)

Offer her a pamphlet about the local battered womens shelter.

)

Call her at home to ask her some questions about her marriage.

)

Wait until she comes in a few more times to make a better assessment.

)

Ask, Have you ever been physically hurt by your partner?

)

Call her at home to ask her some questions about her marriage.

)

Wait until she comes in a few more times to make a better assessment.

)

Ask, Have you ever been physically hurt by your partner?

When describing an episode, the victim reports that she attempted to calm her

partner down to keep things from escalating. This behavior reflects which phase

of the cycle of violence?

)

Battering

)

Honeymoon

)

Tension-building

)

Reconciliation

A battered pregnant woman reports to the nurse that her husband has stopped

hitting her and promises never to hurt her again. Which of the following is an

appropriate response?

)

Thats great. I wish you both the best.

)

The cycle of violence often repeats itself.

)

He probably didnt mean to hurt you.

)

You need to consider leaving him.

Which of the following nursing actions would be least helpful for a client who is

a victim of violence?

)

Assist the client to project her anger.

)

Provide information about a safe home and crisis line.

Teach her about the cycle of violence.

Which of the following nursing actions would be least helpful for a client who is

a victim of violence?

)

Assist the client to project her anger.

)

Provide information about a safe home and crisis line.

)

Teach her about the cycle of violence.

)

Discuss her legal and personal rights.

When describing the cycle of violence to a community group, the nurse explains

that the first phase usually is:

)

Somehow triggered by the victims behavior

)

Characterized by tension-building and minor battery

)

Associated with loss of physical and emotional control

)

Like a honeymoon that lulls the victim

Which of the following statements would be most appropriate to empower

victims of violence to take action?

)

Give your partner more time to come around.

)

Rememberchildren do best in two-parent families.

)

Change your behavior so as not to trigger the violence.

)

You are a good person and you deserve better than this.

)

Rememberchildren do best in two-parent families.

)

Change your behavior so as not to trigger the violence.

)

You are a good person and you deserve better than this.

When a nurse suspects that a client may have been abused, the first action

should be to:

)

Ask the client about the injuries and if they are related to abuse.

)

Encourage the client to leave the batterer immediately.

)

Set up an appointment with a domestic violence counselor.

)

Ask the suspected abuser about the victims injuries.

Which of the following would the nurse describe as a characteristic of the

second phase of the cycle of violence?

)

The batterer is contrite and attempts to apologize for the behavior.

)

The physical battery is abrupt and unpredictable.

)

Verbal assaults begin to escalate toward the victim.

)

The victim accepts the anger as legitimately directed at her.

In addition to providing privacy, which of the following would be most

appropriate initially in situations involving suspected abuse?

)

Allow the client to have a good cry over the situation.

)

Tell the client, Injuries like these dont usually happen by accident.

)

Call the police immediately so they can question the victim.

In addition to providing privacy, which of the following would be most

appropriate initially in situations involving suspected abuse?

)

Allow the client to have a good cry over the situation.

)

Tell the client, Injuries like these dont usually happen by accident.

)

Call the police immediately so they can question the victim.

)

Ask the abuser to describe his side of the story first.

When the nurse is alone with a client, the client says, It was all my fault. The

house was so messy when he got home and I know he hates that. Which

response would be most appropriate?

)

It is not your fault. No one deserves to be hurt.

)

What else did you do to make him so angry with you?

)

You need to start to clean the house early in the day.

)

Remember, he works hard and you need to meet his needs.

When developing a presentation for a local community organization on

violence, the nurse is planning to include statistics on intimate partner abuse and

its effects on children. In what percentage of the cases in which a parent is

abused are the children battered also?

)

50% to 75%

)

25% to 50%

)

10% to 25%

)

Less than 5%

)

50% to 75%

)

25% to 50%

)

10% to 25%

)

Less than 5%

The primary goal when working with victims of intimate partner violence is

to:

)

Convince them to leave the abuser soon

)

Help them cope with their life as it is

)

Empower them to regain control of their life

)

Arrest the abuser so he or she cant abuse again

Teaching for victims who are recovering from abusive situations must focus on

ways to:

)

Enhance their personal appearance and hairstyle

)

Develop their creativity and work ethic

)

Improve their communication skills and assertiveness

)

Plan more nutritious meals to improve their own health

During a follow-up visit to the clinic, a victim of sexual assault reports that she

has changed her job and moved to another town. She tells the nurse, I pretty

much stay to myself at work and at home. The nurse interprets these findings to

indicate that the client is in which phase of rape recovery?

)

Disorganization

)

Denial

)

Reorganization

)

Integration

A nurse is assessing a rape survivor for post-traumatic stress disorder. The nurse

asks the woman, Do you feel as though you are reliving the trauma? The nurse

is assessing for which of the following?

)

Physical symptoms

)

Intrusive thoughts

)

Avoidance

)

Hyperarousal

A group of students are preparing a class discussion about rape and sexual

assault. Which of the following would the students include as being most

accurate? (Select all that apply.)

)

Most victims of rape tell someone about it.

)

Few women falsely cry rape.

)

Women have rape fantasies desiring to be raped.

assault. Which of the following would the students include as being most

accurate? (Select all that apply.)

)

Most victims of rape tell someone about it.

)

Few women falsely cry rape.

)

Women have rape fantasies desiring to be raped.

)

A rape victim feels vulnerable and betrayed afterwards.

)

Medication and counseling can help a rape victim cope.

After teaching a class on date rape, the instructor determines that the teaching

was successful when the class identifies which of the following as the most

common date rape drug?

)

Gamma hydroxybutyrate

)

Liquid ecstasy

)

Ketamine

)

Rohypnol

A nurse is caring for a woman who was recently raped. The nurse would expect

this woman to experience which of the following first?

)

Denial

)

Disorganization

)

Reorganization

)

Integration

)

Denial

)

Disorganization

)

Reorganization

)

Integration

A group of nurses are researching information about risk factors for intimate

partner violence in men. Which of the following would the nurses expect to find

related to the individual person? (Select all that apply.)

)

Dysfunctional family system

)

Low academic achievement

)

Victim of childhood violence

)

Heavy alcohol consumption

)

Economic stress

A nurse is working with a victim of intimate partner violence and helping her

develop a safety plan. Which of the following would the nurse suggest that the

woman take with her? (Select all that apply.)

)

Drivers license

)

Social security number

)

Cash

)

Phone cards

)

Health insurance cards

)

Social security number

)

Cash

)

Phone cards

)

Health insurance cards

A nurse is presenting a discussion on sexual violence at a local community

college. When describing the incidence of sexual violence, the nurse would

identify that a woman has which chance of experiencing a sexual assault in her

lifetime?

)

One in three

)

One in six

)

Two in 15

)

Three in 20

After teaching a class on sexual violence, the instructor determines that the

teaching was successful when the class identifies which of the following as a

type of sexual violence. (Select all that apply.)

)

Female genital cutting

)

Bondage

)

Infanticide

)

Human trafficking

)

Rape

)

Infanticide

)

Human trafficking

)

Rape

A nurse is reading a journal article about sexual abuse. Which age range would

the nurse expect to find as the peak age for such abuse?

)

710 years

)

812 years

)

1418 years

)

1822 years

After teaching a group of students about sexual abuse and violence, the

instructor determines that the teaching was successful when the students

describe incest as involving which of the following?

)

Sexual exploitation by blood or surrogate relatives

)

Sexual abuse of individuals over age 18

)

Violent aggressive assault on a person

)

Consent between perpetrator and victim.

Chapter 10 Fetal Development and Genetics

While talking with a pregnant woman who has undergone genetic testing, the

woman informs the nurse that her baby will be born with Down syndrome. The

nurse understands that Down syndrome is an example of:

)

Multifactorial inheritance

)

X-linked recessive inheritance

)

Trisomy numeric abnormality

)

Chromosomal deletion

A nurse is describing advances in genetics to a group of students. Which of the

following would the nurse least likely include?

)

Genetic diagnosis is now available as early as the second trimester.

)

Genetic testing can identify presymptomatic conditions in children.

)

Gene therapy can be used to repair missing genes with normal ones.

)

Genetic agents may be used in the future to replace drugs.

After teaching a group of students about fetal development, the instructor

determines that the teaching was successful when the students identify which of

the following as providing the barrier to other sperm after fertilization?

)

Zona pellucida

)

Zygote

After teaching a group of students about fetal development, the instructor

determines that the teaching was successful when the students identify which of

the following as providing the barrier to other sperm after fertilization?

)

Zona pellucida

)

Zygote

)

Cleavage

)

Morula

A nurse is teaching a class on X-linked recessive disorders. Which of the

following statements would the nurse most likely include?

)

Males are typically carriers of the disorders.

)

No male-to-male transmission occurs.

)

Daughters are more commonly affected with the disorder.

)

Both sons and daughters have a 50% risk of the disorder.

A pregnant woman undergoes maternal serum alpha-fetoprotein (MSAFP)

testing at 16 to 18 weeks gestation. Which of the following would the nurse

suspect if the womans level is decreased?

)

Down syndrome

)

Sickle-cell anemia

)

Cardiac defects

)

Open neural tube defect

)

Sickle-cell anemia

)

Cardiac defects

)

Open neural tube defect

The nurse is developing a presentation for a community group of young adults

discussing fetal development and pregnancy. The nurse would identify that the

sex of offspring is determined at the time of:

)

Meiosis

)

Fertilization

)

Formation of morula

)

Oogenesis

When describing amniotic fluid to a pregnant woman, the nurse would include

which of the following?

)

This fluid acts as transport mechanism for oxygen and nutrients.

)

The fluid is mostly protein to provide nourishment to your baby.

)

This fluid acts as a cushion to help to protect your baby from injury.

)

The amount of fluid remains fairly constant throughout the pregnancy.

Assessment of a pregnant woman reveals oligohydramnios. The nurse would be

alert for the development of which of the following?

)

Maternal diabetes

)

Placental insufficiency

)

Neural tube defects

Assessment of a pregnant woman reveals oligohydramnios. The nurse would be

alert for the development of which of the following?

)

Maternal diabetes

)

Placental insufficiency

)

Neural tube defects

)

Fetal gastrointestinal malformations

A couple comes to the clinic for preconception counseling and care. As part of

the visit, the nurse teaches the couple about fertilization and initial development,

stating that the zygote formed by the union of the ovum and sperm consists of

how many chromosomes?

)

A woman just delivered a healthy term newborn. Upon assessing the umbilical

cord, the nurse would identify which of the following as normal? (Select all that

apply.)

)

One vein

)

Two veins

)

One artery

)

Two arteries

One ligament

)

One vein

)

Two veins

)

One artery

)

Two arteries

)

One ligament

)

Two ligaments

After teaching a pregnant woman about the hormones produced by the placenta,

the nurse determines that the teaching was successful when the woman

identifies which hormone produced as being the basis for pregnancy tests?

)

Human placental lactogen (hPL)

)

Estrogen (estriol)

)

Progesterone (progestin)

)

Human chorionic gonadotropin (hCG)

After the nurse describes fetal circulation to a pregnant woman, the woman asks

why her fetus has a different circulation pattern than hers. In planning a

response, the nurse integrates understanding of which of the following?

)

Fetal blood is thicker than that of adults and needs different pathways.

)

Fetal circulation carries highly oxygenated blood to vital areas first.

)

Fetal blood has a higher oxygen saturation and circulates more slowly.

)

Fetal heart rates are rapid and circulation time is double that of adults.

)

Fetal blood is thicker than that of adults and needs different pathways.

)

Fetal circulation carries highly oxygenated blood to vital areas first.

)

Fetal blood has a higher oxygen saturation and circulates more slowly.

)

Fetal heart rates are rapid and circulation time is double that of adults.

When describing genetic disorders to a group of childbearing couples, the nurse

would identify which as an example of an autosomal dominant inheritance

disorder?

)

Huntingtons disease

)

Sickle cell disease

)

Phenylketonuria

)

Cystic fibrosis

Prenatal testing is used to assess for genetic risks and to identify genetic

disorders. In explaining to a couple about an elevated alpha-fetoprotein

screening test result, the nurse would discuss the need for:

)

Special care needed for a Down syndrome infant

)

A more specific determination of the acidbase status

)

Further, more definitive evaluations to conclude anything

)

Immediate termination of the pregnancy based on results

A nursing instructor is preparing a teaching plan for a group of nursing students

about the potential for misuse of genetic discoveries and advances. Which the

following would the instructor most likely include?

)

Gene replacement therapy for defective genes

)

Individual risk profiling and confidentiality

)

Greater emphasis on the causes of diseases

)

Slower diagnosis of specific diseases

After teaching a class on the stages of fetal development, the instructor

determines that the teaching was successful when the students identify which of

the following as a stage? (Select all that apply.)

)

Placental

)

Preembryonic

)

Umbilical

)

Embryonic

)

Fetal

A nurse is discussing fetal development with a pregnant woman. The woman is

12 weeks pregnant and asks, Whats happening with my baby? Which of the

following would the nurse integrate into the response? (Select all that apply.)

)

Continued sexual differentiation

)

Eyebrows forming

Startle reflex present

A nurse is discussing fetal development with a pregnant woman. The woman is

12 weeks pregnant and asks, Whats happening with my baby? Which of the

following would the nurse integrate into the response? (Select all that apply.)

)

Continued sexual differentiation

)

Eyebrows forming

)

Startle reflex present

)

Digestive system becoming active

)

Lanugo present on the head

After teaching a group of students about fetal development, the instructor

determines that the teaching was successful when the students identify which of

the following as essential for fetal lung development?

)

Umbilical cord

)

Amniotic fluid

)

Placenta

)

Trophoblasts

During a prenatal class for a group of new mothers, the nurse is describing the

hormones produced by the placenta. Which of the following would the nurse

include? (Select all that apply.)

)

Prolactin

)

Estriol

)

Relaxin

)

Progestin

hormones produced by the placenta. Which of the following would the nurse

include? (Select all that apply.)

)

Prolactin

)

Estriol

)

Relaxin

)

Progestin

)

Human chorionic somatomammotropin

When describing the structures involved in fetal circulation, the nursing

instructor describes which structure as the opening between the right and left

atrium?

)

Ductus venosus

)

Foramen ovale

)

Ductus arteriosus

)

Umbilical artery

A group of students are reviewing information about genetic inheritance. The

students demonstrate understanding of the information when they identify

which of the following as an example of an autosomal recessive disorder?

(Select all that apply.)

)

Cystic fibrosis

)

Phenylketonuria

)

Tay-Sachs disease

)

Polycystic kidney disease

Achondroplasia

)

Cystic fibrosis

)

Phenylketonuria

)

Tay-Sachs disease

)

Polycystic kidney disease

)

Achondroplasia

A nurse is assessing a child with Klinefelters syndrome. Which of the following

would the nurse expect to assess? (Select all that apply.)

)

Gross mental retardation

)

Long arms

)

Profuse body hair

)

Gynecomastia

)

Enlarged testicles

A woman is scheduled to undergo fetal nuchal translucency testing. Which of

the following would the nurse include when describing this test?

)

A needle will be inserted directly into the fetuss umbilical vessel.

)

Youll have an intravaginal ultrasound to measure fluid in the fetus.

)

The doctor will take a sample of fluid from your bag of waters.

)

A small piece of tissue from the fetal part of the placenta is taken.

)

A needle will be inserted directly into the fetuss umbilical vessel.

)

Youll have an intravaginal ultrasound to measure fluid in the fetus.

)

The doctor will take a sample of fluid from your bag of waters.

)

A small piece of tissue from the fetal part of the placenta is taken.

Chapter 11 Maternal Adaptation During Pregnancy

During a vaginal exam, the nurse notes that the cervix has a bluish color. The

nurse documents this finding as:

)

Hegars sign

)

Goodells sign

)

Chadwicks sign

)

Ortolanis sign

The nurse teaches a primigravida client that lightening occurs about 2 weeks

before the onset of labor. The mother will most likely experience which of the

following at that time?

)

Dysuria

)

Dyspnea

)

Constipation

)

Urinary frequency

)

Dyspnea

)

Constipation

)

Urinary frequency

A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, Ive

never urinated as often as I have for the past three weeks. Which response would

be most appropriate for the nurse to make?

)

Having to urinate so often is annoying. I suggest that you watch how much fluid

you are drinking and limit it.

)

You shouldnt be urinating this frequently now; it usually stops by the time youre

eight weeks pregnant. Is there anything else bothering you?

)

By the time you are 12 weeks pregnant, this frequent urination should no longer

be a problem, but it is likely to return toward the end of your pregnancy.

)

Women having their second child generally dont have frequent urination. Are

you experiencing any burning sensations?

In a clients seventh month of pregnancy, she reports feeling dizzy, like Im going

to pass out, when I lie down flat on my back. The nurse integrates which of the

following in to the explanation?

)

Pressure of the gravid uterus on the vena cava

)

A 50% increase in blood volume

)

Physiologic anemia due to hemoglobin decrease

)

Pressure of the presenting fetal part on the diaphragm

A primiparous client is being seen in the clinic for her first prenatal visit. It is

determined that she is 11 weeks pregnant. The nurse develops a teaching plan to

educate the client about what she will most likely experience during this period.

Which of the following would the nurse include?

)

Ankle edema

)

Urinary frequency

)

Backache

)

Hemorrhoids

A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The

nurse interprets this as indicating which of the following?

)

Iron-deficiency anemia

)

A multiple gestation pregnancy

)

Greater-than-expected weight gain

)

Hemodilution of pregnancy

The nurse is discussing the insulin needs of a primaparous client with diabetes

who has been using insulin for the past few years. The nurse informs the client

that her insulin needs will increase during pregnancy based on the nurses

understanding that the placenta produces:

)

hCG, which increases maternal glucose levels

)

hPL, which deceases the effectiveness of insulin

)

Estriol, which interferes with insulin crossing the placenta

that her insulin needs will increase during pregnancy based on the nurses

understanding that the placenta produces:

)

hCG, which increases maternal glucose levels

)

hPL, which deceases the effectiveness of insulin

)

Estriol, which interferes with insulin crossing the placenta

)

Relaxin, which decreases the amount of insulin produced

When teaching a pregnant client about the physiologic changes of pregnancy, the

nurse reviews the effect of pregnancy on glucose metabolism. Which of the

following would the nurse include as the underlying reason for the effect?

)

Pancreatic function is affected by pregnancy.

)

Glucose is utilized more rapidly during a pregnancy.

)

The pregnant woman increases her dietary intake.

)

Glucose moves through the placenta to assist the fetus.

When assessing a woman in her first trimester, which emotional response would

the nurse most likely expect to find?

)

Ambivalence

)

Introversion

)

Acceptance

)

Emotional lability

The nurse is assessing a pregnant woman in the second trimester. Which of the

following tasks would indicate to the nurse that the client is incorporating the

maternal role into her personality?

)

The woman demonstrates concern for herself and her fetus as a unit.

)

The client identifies what she must give up to assume her new role.

)

The woman acknowledges the fetus as a separate entity within her.

)

The client demonstrates unconditional acceptance without rejection.

A woman comes to the prenatal clinic suspecting that she is pregnant, and

assessment reveals probable signs of pregnancy. Which of the following would

be included as part of this assessment? (Select all that apply.)

)

Positive pregnancy test

)

Ultrasound visualization of the fetus

)

Auscultation of a fetal heart beat

)

Ballottement

)

Absence of menstruation

)

Softening of the cervix

The nurse is teaching a pregnant woman about recommended weight gain. The

woman has a prepregnancy body mass index of 26. The nurse determines that

the teaching was successful when the woman states that she should gain no

more than which amount during pregnancy?

)

35 to 40 pounds

)

25 to 35 pounds

)

28 to 40 pounds

)

15 to 25 pounds

A nurse strongly encourages a pregnant client to avoid eating swordfish and

tilefish because these fish contain which of the following?

)

Excess folic acid, which could increase the risk for neural tube defects

)

Mercury, which could harm the developing fetus if eaten in large amounts

)

Lactose, which leads to abdominal discomfort, gas, and diarrhea

)

Low-quality protein that does not meet the womans requirements

Which of the following changes in the musculoskeletal system would the nurse

mention when teaching a group of pregnant women about the physiologic

changes of pregnancy?

)

Ligament tightening

)

Decreased swayback

)

Increased lordosis

mention when teaching a group of pregnant women about the physiologic

changes of pregnancy?

)

Ligament tightening

)

Decreased swayback

)

Increased lordosis

)

Joint contraction

Assessment of a pregnant woman reveals a pigmented line down the middle of

her abdomen. The nurse documents this as which of the following?

)

Linea nigra

)

Striae gravidarum

)

Melasma

)

Vascular spiders

A nurse is assessing a pregnant woman on a routine checkup. When assessing

the womans gastrointestinal tract, which of the following would the nurse

expect to find? (Select all that apply.)

)

Hyperemic gums

)

Increased peristalsis

)

Complaints of bloating

)

Heartburn

)

Nausea

)

Increased peristalsis

)

Complaints of bloating

)

Heartburn

)

Nausea

A woman suspecting she is pregnant asks the nurse about which signs would

confirm her pregnancy. The nurse would explain that which of the following

would confirm the pregnancy?

)

Absence of menstrual period

)

Abdominal enlargement

)

Palpable fetal movement

)

Morning sickness

A nurse is developing a teaching plan about nutrition for a group of pregnant

women. Which of the following would the nurse include in the discussion?

(Select all that apply.)

)

Keep weight gain to 15 lb

)

Eat three meals with snacking

)

Limit the use of salt in cooking

)

Avoid using diuretics

)

Participate in physical activity

)

Limit the use of salt in cooking

)

Avoid using diuretics

)

Participate in physical activity

Assessment of a pregnant woman reveals that she compulsively craves ice. The

nurse documents this finding as which of the following?

)

Quickening

)

Pica

)

Ballottement

)

Linea nigra

A woman in her second trimester comes for a follow-up visit and says to the

nurse, I feel like Im on an emotional roller-coaster. Which response by the nurse

would be most appropriate?

)

How often has this been happening to you?

)

Maybe you need some medication to level things out.

)

Mood swings are completely normal during pregnancy.

)

Have you been experiencing any thoughts of harming yourself?

While talking with a woman in her third trimester, which behavior indicates to

the nurse that the woman is learning to give of oneself?

)

Showing concern for self and fetus as a unit

)

Unconditionally accepting the pregnancy without rejection

While talking with a woman in her third trimester, which behavior indicates to

the nurse that the woman is learning to give of oneself?

)

Showing concern for self and fetus as a unit

)

Unconditionally accepting the pregnancy without rejection

)

Longing to hold infant

)

Questioning ability to become a good mother

A group of students are reviewing the signs of pregnancy. The students

demonstrate understanding of the information when they identify which as

presumptive signs? (Select all that apply.)

)

Amenorrhea

)

Nausea

)

Abdominal enlargement

)

Braxton-Hicks contractions

)

Fetal heart sounds

A nursing instructor is teaching a class to a group of students about pregnancy,

insulin, and glucose. Which of the following would the instructor least likely

include as opposing insulin?

)

Prolactin

)

Estrogen

)

Progesterone

)

Cortisol

insulin, and glucose. Which of the following would the instructor least likely

include as opposing insulin?

)

Prolactin

)

Estrogen

)

Progesterone

)

Cortisol

A woman is at 20 weeks gestation. The nurse would expect to find the fundus at

which of the following?

)

Just above the symphysis pubis

)

Mid-way between the pubis and umbilicus

)

At the level of the umbilicus

)

Mid-way between the umbilicus and xiphoid process

A pregnant woman comes to the clinic and tells the nurse that she has been

having a whitish vaginal discharge. The nurse suspects vulvovaginal candidiasis

based on which assessment finding?

)

Fever

)

Vaginal itching

)

Urinary frequency

)

Incontinence

)

Vaginal itching

)

Urinary frequency

)

Incontinence

Chapter 12 Nursing Management During Pregnancy

A woman in the 34th week of pregnancy says to the nurse, I still feel like having

intercourse with my husband. The womans pregnancy has been uneventful. The

nurse responds based on the understanding that:

)

It is safe to have intercourse at this time.

)

Intercourse at this time is likely to cause rupture of membranes.

)

There are other ways that the couple can satisfy their needs.

)

Intercourse at this time is likely to result in premature labor.

On the first prenatal visit, examination of the womans internal genitalia reveals a

bluish coloration of the cervix and vaginal mucosa. The nurse records this

finding as:

)

Hegars sign

)

Goodells sign

)

Chadwicks sign

)

Homans sign

)

Hegars sign

)

Goodells sign

)

Chadwicks sign

)

Homans sign

When describing perinatal education to a pregnant woman and her partner, the

nurse emphasizes that the primary goal of these classes is to:

)

Equip a couple with the knowledge to experience a pain-free childbirth

)

Provide knowledge and skills to actively participate in birth and parenting

)

Eliminate anxiety so that they can have an uncomplicated birth

)

Empower the couple to totally control the birth process

When assessing a woman at follow-up prenatal visits, the nurse would anticipate

which of the following to be performed?

)

Hemoglobin and hematocrit

)

Urine for culture

)

Fetal ultrasound

)

Fundal height measurement

During a routine prenatal visit, a client, 36 weeks pregnant, states she has

difficulty breathing and feels like her pulse rate is really fast. The nurse finds her

pulse to be 100 beats per minute (increased from baseline readings of 70 to 74

beats per minute. and irregular, with bilateral crackles in the lower lung bases.

Which nursing diagnosis would be the priority for this client?

)

Ineffective tissue perfusion related to supine hypotensive syndrome

)

Impaired gas exchange related to pulmonary congestion

)

Activity intolerance related to increased metabolic requirements

)

Anxiety related to fear of pregnancy outcome

When preparing a woman for an amniocentesis, the nurse would instruct her to

do which of the following?

)

Shower with an antiseptic scrub.

)

Swallow the preprocedure sedative.

)

Empty her bladder.

)

Lie on her left side.

A client who is 4 months pregnant is at the prenatal clinic for her initial visit.

Her history reveals she has 7-year-old twins who were born at 34 weeks

gestation, a 2-year old son born at 39 weeks gestation, and a spontaneous

abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse

would document her obstetric history as:

)

3 2 1 0 3

)

3 1 2 2 3

Her history reveals she has 7-year-old twins who were born at 34 weeks

gestation, a 2-year old son born at 39 weeks gestation, and a spontaneous

abortion 1 year ago at 6 weeks gestation. Using the GTPAL method, the nurse

would document her obstetric history as:

)

3 2 1 0 3

)

3 1 2 2 3

)

4 1 1 1 3

)

4 2 1 3 1

A clients last menstrual period was April 11. Using Nageles rule, her expected

date of birth (EDB. would be:

)

January 4

)

January 18

)

January 25

)

February 24

During a nonstress test, when monitoring the fetal heart rate, the nurse notes that

when the expectant mother reports fetal movement, the heart rate increases 15

beats or more above the baseline. The nurse interprets this as:

)

Variable decelerations

)

Fetal tachycardia

)

A nonreactive pattern

)

Reactive pattern

)

Fetal tachycardia

)

A nonreactive pattern

)

Reactive pattern

A clients maternal serum alpha-fetoprotein (MSAFP. level was unusually

elevated at 17 weeks. The nurse suspects which of the following?

)

Fetal hypoxia

)

Open spinal defects

)

Down syndrome

)

Maternal hypertension

When assessing a pregnant woman in her last trimester, which question would

be most appropriate to use to gather information about weight gain and fluid

retention?

)

Whats your usual dietary intake for a typical day?

)

What size maternity clothes are you wearing now?

)

How puffy does your face look by the end of a day?

)

How swollen do your ankles appear before you go to bed?

A pregnant woman in the 36th week of gestation complains that her feet are

quite swollen at the end of the day. After careful assessment, the nurse

determines that this is an expected finding at this stage of pregnancy. Which

intervention would be most appropriate for the nurse to suggest?

)

Limit your intake of fluids.

)

Eliminate salt from your diet.

)

Try elevating your legs when you sit.

)

Wear Spandex-type full-length pants.

A pregnant woman needs an update in her immunizations. Which of the

following vaccinations would the nurse ensure that the woman receives?

)

Measles

)

Mumps

)

Rubella

)

Hepatitis B

A pregnant woman is flying across the country to visit her family. After

teaching the woman about traveling during pregnancy, which statement

indicates that the teaching was successful?

)

Ill sit in a window seat so I can focus on the sky to help relax me.

)

I wont drink too much fluid so I dont have to urinate so often.

)

Ill get up and walk around the airplane about every 2 hours.

teaching the woman about traveling during pregnancy, which statement

indicates that the teaching was successful?

)

Ill sit in a window seat so I can focus on the sky to help relax me.

)

I wont drink too much fluid so I dont have to urinate so often.

)

Ill get up and walk around the airplane about every 2 hours.

)

Ill do some upper arm stretches while sitting in my seat.

Which of the following would the nurse include when teaching a pregnant

woman about chorionic villus sampling?

)

The results should be available in about a week.

)

Youll have an ultrasound first and then the test.

)

Afterwards, you can resume your exercise program.

)

This test is very helpful for identifying spinal defects.

A pregnant woman is scheduled to undergo percutaneous umbilical blood

sampling. When discussing this test with the woman, the nurse reviews what

can be evaluated with the specimens collected. Which of the following would

the nurse include? (Select all that apply.)

)

Rh incompatibility

)

Fetal acidbase status

)

Sex-linked disorders

)

Enzyme deficiencies

)

Coagulation studies

)

Fetal acidbase status

)

Sex-linked disorders

)

Enzyme deficiencies

)

Coagulation studies

A biophysical profile has been completed on a pregnant woman. The nurse

interprets which score as normal?

)

After teaching a group of students about the discomforts of pregnancy, the

students demonstrate understanding of the information when they identify

which as common during the first trimester? (Select all that apply.)

)

Urinary frequency

)

Breast tenderness

)

Cravings

)

Backache

)

Leg cramps

)

Cravings

)

Backache

)

Leg cramps

A nurse is reviewing the medical record of a pregnant woman and notes that she

is gravid II. The nurse interprets this to indicate the number of:

)

Deliveries

)

Pregnancies

)

Spontaneous abortions

)

Pre-term births

A nurse measures a pregnant womans fundal height and finds it to be 28 cm.

The nurse interprets this to indicate which of the following?

)

14 weeks gestation

)

20 weeks gestation

)

28 weeks gestation

)

36 weeks gestation

A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse

explains that this test measures which of the following?

)

Platelet level

)

Rh status

A pregnant woman has a rubella titer drawn on her first prenatal visit. The nurse

explains that this test measures which of the following?

)

Platelet level

)

Rh status

)

Immunity to German measles

)

Red blood cell count

A nurse is working with a pregnancy woman to schedule follow-up visits for her

pregnancy. Which statement by the woman indicates that she understands the

scheduling?

)

I need to make visits every 2 months until Im 36 weeks pregnant.

)

Once I get to 28 weeks, I have to come twice a month.

)

From now until Im 28 weeks, Ill be coming once a month.

)

Ill make sure to get a day off every 2 weeks to make my visits.

A nursing instructor is describing the various childbirth methods. Which of the

following would the instructor include as part of the Lamaze method?

)

Focus on the pleasurable sensations of childbirth

)

Concentration on sensations while turning on to own bodies

)

Interruption of the fear-tension-pain cycle

)

Use of specific breathing and relaxation techniques

)

Focus on the pleasurable sensations of childbirth

)

Concentration on sensations while turning on to own bodies

)

Interruption of the fear-tension-pain cycle

)

Use of specific breathing and relaxation techniques

After teaching a group of students about the different perinatal education

methods, the instructor determines that the teaching was successful when the

students identify which of the following as the Bradley method?

)

Psychoprophylactic method

)

Partner-coached method

)

Natural childbirth method

)

Mind prevention method

A pregnant woman in her second trimester tells the nurse, Ive been passing a lot

of gas and feel bloated. Which of the following suggestions would be helpful

for the woman?

)

Watch how much beans and onions you eat.

)

Limit the amount of fluid you drink with meals

)

Try exercising a little more.

)

Some say that eating mints can help.

)

Cut down on your intake of cheeses.

)

Try exercising a little more.

)

Some say that eating mints can help.

)

Cut down on your intake of cheeses.

Chapter 13 Labor and Birth Process

A woman in her 40th week of pregnancy calls the nurse at the clinic and says

shes not sure whether she is in true or false labor. Which statement by the client

would lead the nurse to suspect that the woman is experiencing false labor?

)

Im feeling contractions mostly in my back.

)

My contractions are about 6 minutes apart and regular.

)

The contractions slow down when I walk around.

)

If I try to talk to my partner during a contraction, I cant.

Which of the following would indicate to the nurse that the placenta is

separating?

)

Uterus becomes globular

)

Fetal head is at vaginal opening

)

Umbilical cord shortens

)

Mucous plug is expelled

)

Fetal head is at vaginal opening

)

Umbilical cord shortens

)

Mucous plug is expelled

When assessing cervical effacement of a client in labor, the nurse assesses which

of the following characteristics?

)

Extent of opening to its widest diameter

)

Degree of thinning

)

Passage of the mucous plug

)

Fetal presenting part

A woman calls the health care facility stating that she is in labor. The nurse

would urge the client to come to the facility if the client reports which of the

following?

)

Increased energy level with alternating strong and weak contractions

)

Moderately strong contractions every 4 minutes, lasting about 1 minute

)

Contractions noted in the front of abdomen that stop when she walks

)

Pink-tinged vaginal secretions and irregular contractions lasting about 30

seconds

A woman is in the first stage of labor. The nurse would encourage her to assume

which position to facilitate the progress of labor?

)

Supine

)

Lithotomy

Upright

A woman is in the first stage of labor. The nurse would encourage her to assume

which position to facilitate the progress of labor?

)

Supine

)

Lithotomy

)

Upright

)

Kneechest

A client has not received any medication during her labor. She is having frequent

contractions every 1 to 2 minutes and has become irritable with her coach and no

longer will allow the nurse to palpate her fundus during contractions. Her cervix

is 8 cm dilated and 90% effaced. The nurse interprets these findings as

indicating:

)

Latent phase of the first stage of labor

)

Active phase of the first stage of labor

)

Transition phase of the first stage of labor

)

Pelvic phase of the second stage of labor

The fetus of a nulliparous woman is in a shoulder presentation. The nurse would

most likely prepare the client for which type of birth?

)

Cesarean

)

Vaginal

)

Forceps-assisted

)

Vacuum extraction

)

Cesarean

)

Vaginal

)

Forceps-assisted

)

Vacuum extraction

Assessment of a woman in labor reveals cervical dilation of 3 cm, cervical

effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting

about 40 seconds. The nurse determines that this client is in:

)

Latent phase of the first stage

)

Active phase of the first stage

)

Transition phase of the first stage

)

Perineal phase of the second stage

A client is admitted to the labor and birthing suite in early labor. On review of

her medical record, the nurse determines that the clients pelvic shape as

identified in the antepartal progress notes is the most favorable one for a vaginal

delivery. Which pelvic shape would the nurse have noted?

)

Platypelloid

)

Gynecoid

)

Android

)

Anthropoid

A woman telephones her health care provider and reports that her water just

broke. Which suggestion by the nurse would be most appropriate?

)

Call us back when you start having contractions.

)

Come to the clinic or emergency department for an evaluation.

)

Drink 3 to 4 glasses of water and lie down.

)

Come in as soon as you feel the urge to push.

After teaching a group of students about the maternal bony pelvis, which

statement by the group indicates that the teaching was successful?

)

The bony pelvis plays a lesser role during labor than soft tissue.

)

The pelvic outlet is associated with the true pelvis.

)

The false pelvis lies below the imaginary linea terminalis.

)

The false pelvis is the passageway through which the fetus travels.

A fetus is assessed at 2 cm above the ischial spines. The nurse would document

fetal station as:

)

fetal station as:

)

Assessment of a fetus identifies the buttocks as the presenting part, with the legs

extended upward. The nurse identifies this as which type of breech

presentation?

)

Frank

)

Full

)

Complete

)

Footling

A woman in her third trimester comes to the clinic for a prenatal visit. During

assessment the woman reports that her breathing has become much easier in the

last week but she has noticed increased pelvic pressure , cramping and lower

back pain. The nurse determines that which of the following has most likely

occurred?

)

Cervical dilation

)

Lightening

)

Bloody show

)

Braxton-Hicks contractions

)

Lightening

)

Bloody show

)

Braxton-Hicks contractions

After teaching a group of students about the factors affecting the labor process,

the instructor determines that the teaching was successful when the group

identifies which of the following as a component of the true pelvis? (Select all

that apply.)

)

Pelvic inlet

)

Cervix

)

Mid pelvis

)

Pelvic outlet

)

Vagina

)

Pelvic floor muscles

A nurse is documenting fetal lie of a woman in labor. Which term would the

nurse most likely use?

)

Flexion

)

Extension

)

Longitudinal

)

Cephalic

)

Extension

)

Longitudinal

)

Cephalic

The nurse is reviewing the medical record of a woman in labor and notes that

the fetal position is documented as LSA. The nurse interprets this information as

indicating which of the following is the presenting part?

)

Occiput

)

Face

)

Buttocks

)

Shoulder

A nurse is preparing a class for pregnant women about labor and birth. When

describing the typical movements that the fetus goes through as it travels

through the passageway, which of the following would the nurse most likely

include? (Select all that apply.)

)

Internal rotation

)

Abduction

)

Descent

)

Pronation

)

Flexion

The nurse is reviewing the monitoring strip of a woman in labor who is

experiencing a contraction. The nurse notes the time the contraction takes from

its onset to reach its highest intensity. The nurse interprets this time as which of

the following?

)

Increment

)

Acme

)

Peak

)

Decrement

A nurse is assessing a woman in labor. Which finding would the nurse identify

as a cause for concern during a contraction?

)

Heart rate increase from 76 bpm to 90 bpm

)

Blood pressure rise from 110/60 mm Hg to 120/74

)

White blood cell count of 12,000 cells/mm3

)

Respiratory rate of 10 breaths /minute

When describing the stages of labor to a pregnant woman, which of the

following would the nurse identify as the major change occurring during the

first stage?

)

Regular contractions

)

Cervical dilation

)

Fetal movement through the birth canal

following would the nurse identify as the major change occurring during the

first stage?

)

Regular contractions

)

Cervical dilation

)

Fetal movement through the birth canal

)

Placental separation

A nurse is caring for several women in labor. The nurse determines that which

woman is in the transition phase of labor?

)

Contractions every 5 minutes, cervical dilation 3 cm

)

Contractions every 3 minutes, cervical dilation 5 cm

)

Contractions every 2 minutes, cervical dilation 7 cm

)

Contractions every 1 minute, cervical dilation 9 cm

A nurse is preparing a presentation for a group of pregnant women about the

labor experience. Which of the following would the nurse most likely include

when discussing measures to promote coping for a positive labor experience?

(Select all that apply.)

)

Presence of a support partner

)

View of birth as a stressor

)

Low anxiety level

)

Fear of loss of control

)

Participation in a pregnancy exercise program

)

View of birth as a stressor

)

Low anxiety level

)

Fear of loss of control

)

Participation in a pregnancy exercise program

During a follow-up prenatal visit, a pregnant woman asks the nurse, How long

do you think I will be in labor? Which response by the nurse would be most

appropriate?

)

Its difficult to predict how your labor will progress, but well be there for you the

entire time.

)

Since this is your first pregnancy, you can estimate it will be about 10 hours.

)

It will depend on how big the baby is when you go into labor.

)

Time isnt important; your health and the babys health are key.

A nurse is describing how the fetus moves through the birth canal. Which of the

following would the nurse identify as being most important in allowing the fetal

head to move through the pelvis?

)

Sutures

)

Fontanelles

)

Frontal bones

)

Biparietal diameter

Assessment of a pregnant woman reveals that the presenting part of the fetus is

at the level of the maternal ischial spines. The nurse documents this as which

station?

)

Chapter 14 Nursing Management During Labor and Birth

A woman in labor who received an opioid for pain relief develops respiratory

depression. The nurse would expect which agent to be administered?

)

Butorphanol

)

Fentanyl

)

Naloxone

)

Promethazine

)

Naloxone

)

Promethazine

A clients membranes spontaneously ruptured, as evidenced by a gush of clear

fluid with a contraction. Which of the following would the nurse do next?

)

Check the fetal heart rate.

)

Perform a vaginal exam.

)

Notify the physician immediately.

)

Change the linen saver pad.

A woman has just entered the second stage of labor. The nurse would focus care

on which of the following?

)

Encouraging the woman to push when she has a strong desire to do so

)

Alleviating perineal discomfort with the application of ice packs

)

Palpating the womans fundus for position and firmness

)

Completing the identification process of the newborn with the mother

The nurse notes persistent early decelerations on the fetal monitoring strip.

Which of the following would the nurse do next?

)

Continue to monitor the FHR because this pattern is benign.

)

Perform a vaginal exam to assess cervical dilation and effacement.

)

Stay with the client while reporting the finding to the physician.

)

Administer oxygen after turning the client on her left side.

)

Continue to monitor the FHR because this pattern is benign.

)

Perform a vaginal exam to assess cervical dilation and effacement.

)

Stay with the client while reporting the finding to the physician.

)

Administer oxygen after turning the client on her left side.

A woman is admitted to the labor and birthing suite. Vaginal examination

reveals that the presenting part is approximately 2 cm above the ischial spines.

The nurse documents this finding as:

)

+2 station

)

0 station

)

2 station

)

Crowning

The nurse is performing Leopolds maneuvers to determine fetal presentation,

position, and lie. Which action would the nurse do first?

)

Feel for the fetal buttocks or head while palpating the abdomen.

)

Feel for the fetal back and limbs as the hands move laterally on the abdomen.

)

Palpate for the presenting part in the area just above the symphysis pubis.

)

Determine flexion by pressing downward toward the symphysis pubis.

A client states, I think my waters broke! I felt this gush of fluid between my legs.

The nurse tests the fluid with Nitrazine paper and confirms membrane rupture if

the paper turns:

)

Yellow

)

Olive green

)

Pink

)

Blue

A woman in labor is to receive continuous internal electronic fetal monitoring.

The nurse reviews the womans medical record to ensure which of the following

as being required?

)

Intact membranes

)

Cervical dilation of 2 cm or more

)

Floating presenting fetal part

)

A neonatologist to insert the electrode

When assessing fetal heart rate, the nurse finds a heart rate of 175 bpm,

accompanied by a decrease in variability and late decelerations. Which of the

following would the nurse do next?

)

Have the woman change her position.

)

Administer oxygen.

)

Notify the health care provider.

Continue to monitor the pattern every 15 minutes.

accompanied by a decrease in variability and late decelerations. Which of the

following would the nurse do next?

)

Have the woman change her position.

)

Administer oxygen.

)

Notify the health care provider.

)

Continue to monitor the pattern every 15 minutes.

A woman in labor has chosen to use hydrotherapy as a method of pain relief.

Which statement by the woman would lead the nurse to suspect that the woman

needs additional teaching?

)

The warmth and buoyancy of the water has a nice relaxing effect.

)

I can stay in the bath for as long as I feel comfortable.

)

My cervix should be dilated more than 5 cm before I try using this method.

)

The temperature of the water should be at least 105 F.

A woman in labor received an opioid close to the time of birth. The nurse would

assess the newborn for which of the following?

)

Respiratory depression

)

Urinary retention

)

Abdominal distention

)

Hyperreflexia

)

Urinary retention

)

Abdominal distention

)

Hyperreflexia

When applying the ultrasound transducers for continuous external electronic

fetal monitoring, at which location would the nurse place the transducer to

record the FHR?

)

Over the uterine fundus where contractions are most intense

)

Above the umbilicus toward the right side of the diaphragm

)

Between the umbilicus and the symphysis pubis

)

Between the xiphoid process and umbilicus

After describing continuous internal electronic fetal monitoring to a laboring

woman and her partner, which of the following would indicate the need for

additional teaching?

)

This type of monitoring is the most accurate method for our baby.

)

Unfortunately, Im going to have to stay quite still in bed while it is in place.

)

This type of monitoring can only be used after my membranes rupture.

)

Youll be inserting a special electrode into my babys scalp.

When planning the care of a woman in the active phase of labor, the nurse

would anticipate assessing the fetal heart rate at which interval?

)

Every 2 to 4 hours

)

Every 45 to 60 minutes

When planning the care of a woman in the active phase of labor, the nurse

would anticipate assessing the fetal heart rate at which interval?

)

Every 2 to 4 hours

)

Every 45 to 60 minutes

)

Every 15 to 30 minutes

)

Every 10 to 15 minutes

Which of the following is a priority when caring for a woman during the fourth

stage of labor?

)

Assessing the uterine fundus

)

Offering fluids as indicated

)

Encouraging the woman to void

)

Assisting with perineal care

When palpating the fundus during a contraction, the nurse notes that it feels like

a chin. The nurse interprets this finding as indicating which type of contraction?

)

Intense

)

Strong

)

Moderate

)

Mild

)

Intense

)

Strong

)

Moderate

)

Mild

A nurse palpates a womans fundus to determine contraction intensity. Which of

the following would be most appropriate for the nurse to use for palpation?

)

Finger pads

)

Palm of the hand

)

Finger tips

)

Back of the hand

A womans amniotic fluid is noted to be cloudy. The nurse interprets this finding

as which of the following?

)

Normal

)

Possible infection

)

Meconium passage

)

Transient fetal hypoxia

After teaching a group of students about fetal heart rate patterns, the instructor

determines the need for additional teaching when the students identify which of

the following as indicating normal fetal acidbase status? (Select all that apply.)

)

Sinusoidal pattern

)

Recurrent variable decelerations

)

Fetal bradycardia

)

Absence of late decelerations

)

Moderate baseline variability

A nurse is reviewing the fetal heart rate pattern and observes abrupt decreases in

FHR below the baseline, appearing as a U-shape. The nurse interprets these

changes as reflecting which of the following?

)

Early decelerations

)

Variable decelerations

)

Prolonged decelerations

)

Late decelerations

A nurse is explaining the use of therapeutic touch as a pain relief measure

during labor. Which of the following would the nurse include in the

explanation?

)

This technique focuses on manipulating body tissues.

)

The technique requires focusing on a specific stimulus.

This technique redirects energy fields that lead to pain.

A nurse is explaining the use of therapeutic touch as a pain relief measure

during labor. Which of the following would the nurse include in the

explanation?

)

This technique focuses on manipulating body tissues.

)

The technique requires focusing on a specific stimulus.

)

This technique redirects energy fields that lead to pain.

)

The technique involves light stroking of the abdomen with breathing.

A group of nursing students are reviewing the various medications used for pain

relief during labor. The students demonstrate understanding of the information

when they identify which agent as the most commonly used opioid?

)

Butorphanol

)

Nalbuphine

)

Fentanyl

)

Meperidine

A nurse is describing the different types of regional analgesia and anesthesia for

labor to a group of pregnant women. Which statement by the group indicates

that the teaching was successful?

)

We can get up and walk around after receiving combined spinalepidural

analgesia.

)

Higher anesthetic doses are needed for patient-controlled epidural analgesia.

)

A pudendal nerve block is highly effective for pain relief in the first stage of

labor.

)

Local infiltration using lidocaine is an appropriate method for controlling

contraction pain.

)

We can get up and walk around after receiving combined spinalepidural

analgesia.

)

Higher anesthetic doses are needed for patient-controlled epidural analgesia.

)

A pudendal nerve block is highly effective for pain relief in the first stage of

labor.

)

Local infiltration using lidocaine is an appropriate method for controlling

contraction pain.

A nurse is completing the assessment of a woman admitted to the labor and

birth suite. Which of the following would the nurse expect to include as part of

the physical assessment? (Select all that apply.)

)

Current pregnancy history

)

Fundal height measurement

)

Support system

)

Estimated date of birth

)

Membrane status

)

Contraction pattern

A pregnant woman admitted to the labor and birth suite undergoes rapid HIV

testing and is found to be HIV-positive. Which of the following would the nurse

expect to include when developing a plan of care for this women? (Select all

that apply.)

)

Administration of penicillin G at the onset of labor

)

Avoidance of scalp electrodes for fetal monitoring

)

Refraining from obtaining fetal scalp blood for pH testing

)

Adminstering zidovudine at the onset of labor.

)

Administration of penicillin G at the onset of labor

)

Avoidance of scalp electrodes for fetal monitoring

)

Refraining from obtaining fetal scalp blood for pH testing

)

Adminstering zidovudine at the onset of labor.

)

Electing for the use of forceps-assisted delivery

Which position would be most appropriate for the nurse to suggest as a comfort

measure to a woman who is in the first stage of labor? (Select all that apply.)

)

Walking with partner support

)

Straddling with forward leaning over a chair

)

Closed kneechest position

)

Rocking back and forth with foot on chair

)

Supine with legs raised at a 90-degree angle

Which of the following would be most appropriate for the nurse to suggest

about pushing to a woman in the second stage of labor?

)

Lying flat with your head elevated on two pillows makes pushing easier.

)

Choose whatever method you feel most comfortable with for pushing.

)

Let me help you decide when it is time to start pushing.

)

Bear down like youre having a bowel movement with every contraction.

)

Lying flat with your head elevated on two pillows makes pushing easier.

)

Choose whatever method you feel most comfortable with for pushing.

)

Let me help you decide when it is time to start pushing.

)

Bear down like youre having a bowel movement with every contraction.

A nurse is assessing a woman after birth and notes a second-degree laceration.

The nurse interprets this as indicating that the tear extends through which of the

following?

)

Skin

)

Muscles of perineal body

)

Anal sphincter

)

Anterior rectal wall

A nurse is assisting with the delivery of a newborn. The fetal head has just

emerged. Which of the following would be done next?

)

Suctioning of the mouth and nose

)

Clamping of the umbilical cord

)

Checking for the cord around the neck

)

Drying of the newborn

A nurse is providing care to a woman during the third stage of labor. Which of

the following would alert the nurse that the placenta is separating? (Select all

that apply.)

)

Boggy, soft uterus

)

Uterus becoming discoid shaped

)

Sudden gush of dark blood from the vagina

)

Shortening of the umbilical cord

Chapter 15 Postpartum Adaptations

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago.

The nurse palpates the clients fundus, expecting it to be at which location?

)

Two fingerbreadths above the umbilicus

)

At the level of the umbilicus

)

Two fingerbreadths below the umbilicus

Four fingerbreadths below the umbilicus

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago.

The nurse palpates the clients fundus, expecting it to be at which location?

)

Two fingerbreadths above the umbilicus

)

At the level of the umbilicus

)

Two fingerbreadths below the umbilicus

)

Four fingerbreadths below the umbilicus

When caring for a mother who has had a cesarean birth, the nurse would expect

the clients lochia to be:

)

Greater than after a vaginal delivery

)

About the same as after a vaginal delivery

)

Less than after a vaginal delivery

)

Saturated with clots and mucus

The nurse is developing a teaching plan for a client who has decided to bottle

feed her newborn. Which of the following would the nurse include in the

teaching plan to facilitate suppression of lactation?

)

Encouraging the woman to manually express milk

)

Suggesting that she take frequent warm showers to soothe her breasts

)

Telling her to limit the amount of fluids that she drinks

)

Instructing her to apply ice packs to both breasts every other hour

The nurse is making a follow-up home visit to a woman who is 12 days

postpartum. Which of the following would the nurse expect to find when

assessing the clients fundus?

)

Cannot be palpated

)

2 cm below the umbilicus

)

6 cm below the umbilicus

)

10 cm below the umbilicus

A client who is breast-feeding her newborn tells the nurse, I notice that when I

feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I

having contractions now? Which response by the nurse would be most

appropriate?

)

Your uterus is still shrinking in size; thats why youre feeling this pain.

)

Let me check your vaginal discharge just to make sure everything is fine.

)

Your body is responding to the events of labor, just like after a tough workout.

)

The babys sucking releases a hormone that causes the uterus to contract.

When the nurse is assessing a postpartum client approximately 6 hours after

delivery, which finding would warrant further investigation?

)

Deep red, fleshy-smelling lochia

)

Voiding of 350 cc

)

Heart rate of 120 beats/minute

When the nurse is assessing a postpartum client approximately 6 hours after

delivery, which finding would warrant further investigation?

)

Deep red, fleshy-smelling lochia

)

Voiding of 350 cc

)

Heart rate of 120 beats/minute

)

Profuse sweating

A postpartum client who is bottle feeding her newborn asks, When should my

period return? Which response by the nurse would be most appropriate?

)

Its difficult to say, but it will probably return in about 2 to 3 weeks.

)

It varies, but you can estimate it returning in about 7 to 9 weeks.

)

You wont have to worry about it returning for at least 3 months.

)

You dont have to worry about that now. Itll be quite a while.

The nurse interprets which of the following as evidence that a client is in the

taking-in phase?

)

Client states, He has my eyes and nose.

)

Client shows interest in caring for the newborn.

)

Client performs self-care independently.

)

Client confidently cares for the newborn.

Which of the following would the nurse interpret as being least indicative of

paternal engrossment?

)

Demonstrating pleasure when touching or holding the newborn

)

Identifying imperfections in the newborns appearance

)

Being able to distinguish his newborn from others in the nursery

)

Showing feelings of pride with the birth of the newborn

A postpartum client comes to the clinic for her 6-week postpartum checkup.

When assessing the clients cervix, the nurse would expect the external cervical

os to appear:

)

Shapeless

)

Circular

)

Triangular

)

Slit-like

The nurse develops a teaching plan for a postpartum client and includes

teaching about how to perform Kegel exercises. The nurse includes this

information for which reason?

)

Reduce lochia

)

Promote uterine involution

)

Improve pelvic floor tone

)

Alleviate perineal pain

teaching about how to perform Kegel exercises. The nurse includes this

information for which reason?

)

Reduce lochia

)

Promote uterine involution

)

Improve pelvic floor tone

)

Alleviate perineal pain

A father of a newborn tells the nurse, I may not know everything about being a

dad, but Im going to do the best I can for my son. The nurse interprets this as

indicating the father is in which stage of adaptation?

)

Expectations

)

Transition to mastery

)

Reality

)

Taking-in

A postpartum client is experiencing subinvolution. When reviewing the womans

labor and birth history, which of the following would the nurse identify as being

least significant to this condition?

)

Early ambulation

)

Prolonged labor

)

Large fetus

)

Use of anesthetics

)

Prolonged labor

)

Large fetus

)

Use of anesthetics

Which of the following would lead the nurse to suspect that a postpartum

woman is experiencing a problem?

)

Elevated white blood cell count

)

Acute decrease in hematocrit

)

Increased levels of clotting factors

)

Pulse rate of 60 beats/minute

A woman who gave birth 24 hours ago tells the nurse, Ive been urinating so

much over the past several hours. Which response by the nurse would be most

appropriate?

)

You must have an infection, so let me get a urine specimen.

)

Your body is undergoing many changes that cause your bladder to fill quickly.

)

Your uterus is not contracting as quickly as it should.

)

The anesthesia that you received is wearing off and your bladder is working

again.

A group of students are reviewing the process of breast milk production. The

students demonstrate understanding when they identify which hormone as

responsible for milk let-down?

)

Prolactin

)

Estrogen

)

Progesterone

)

Oxytocin

A nurse is making a home visit to a postpartum woman who delivered a healthy

newborn 4 days ago. The womans breasts are swollen, hard, and tender to the

touch. The nurse documents this finding as which of the following?

)

Involution

)

Engorgement

)

Mastitis

)

Engrossment

A nurse is assessing a postpartum womans adjustment to her maternal role.

Which of the following would the nurse expect to occur first?

)

Reestablishing relationships with others

)

Demonstrating increasing confidence in care of the newborn

)

Assuming a passive role in meeting her own needs

Becoming preoccupied with the present

Which of the following would the nurse expect to occur first?

)

Reestablishing relationships with others

)

Demonstrating increasing confidence in care of the newborn

)

Assuming a passive role in meeting her own needs

)

Becoming preoccupied with the present

The partner of a woman who has given birth to a healthy newborn says to the

nurse, I want to be involved, but Im not sure that Im able to care for such a little

baby. The nurse interprets this as indicating which of the following stages?

)

Expectations

)

Reality

)

Transition to mastery

)

Taking-hold

A group of nursing students are reviewing information about maternal and

paternal adaptations to the birth of a newborn. The nurse observes the parents

interacting with their newborn physically and emotionally. The nurse

documents this as which of the following?

)

Puerperium

)

Lactation

)

Attachment

)

Engrossment

)

Lactation

)

Attachment

)

Engrossment

After teaching a group of nursing students about the process of involution, the

instructor determines that additional teaching is needed when the students

identify which of the following as being involved?

)

Catabolism

)

Muscle fiber contraction

)

Epithelial regeneration

)

Vasodilation

A nurse is visiting a postpartum woman who delivered a healthy newborn 5

days ago. Which of the following would the nurse expect to find?

)

Bright red discharge

)

Pinkish brown discharge

)

Deep red mucus-like discharge

)

Creamy white discharge

A nurse teaches a postpartum woman about her risk for thromboembolism.

Which of the following would the nurse be least likely to include as a factor

increasing her risk?

)

Increased clotting factors

)

Vessel damage

A nurse teaches a postpartum woman about her risk for thromboembolism.

Which of the following would the nurse be least likely to include as a factor

increasing her risk?

)

Increased clotting factors

)

Vessel damage

)

Immobility

)

Increased red blood cell production

A nursing student is preparing a class presentation about changes in the various

body systems during the postpartum period and their effects. Which of the

following would the student include as influencing a postpartum womans ability

to void? (Select all that apply.)

)

Use of an opioid anesthetic during labor

)

Generalized swelling of the perineum

)

Decreased bladder tone from regional anesthesia

)

Use of oxytocin to augment labor

)

Need for an episiotomy

A postpartum woman who has experienced diastasis recti asks the nurse about

what to expect related to this condition. Which response by the nurse would be

most appropriate?

)

Youll notice that this will fade to silvery lines.

)

Exercise will help to improve the muscles.

)

Expect the color to lighten somewhat.

Youll notice that your shoe size will increase.

what to expect related to this condition. Which response by the nurse would be

most appropriate?

)

Youll notice that this will fade to silvery lines.

)

Exercise will help to improve the muscles.

)

Expect the color to lighten somewhat.

)

Youll notice that your shoe size will increase.

A group of nursing students are reviewing respiratory system adaptations that

occur during the postpartum period. The students demonstrate understanding of

the information when they identify which of the following as a postpartum

adaptation?

)

Continued shortness of breath

)

Relief of rib aching

)

Diaphragmatic elevation

)

Decrease in respiratory rate

A woman who delivered a healthy newborn several hours ago asks the nurse,

Why am I perspiring so much? The nurse integrates knowledge that a decrease

in which hormone plays a role in this occurrence?

)

Estrogen

)

hCG

)

hPL

)

Progesterone

)

hCG

)

hPL

)

Progesterone

Chapter 16 Nursing Management During the Postpartum Period

A woman who is 12 hours postpartum had a pulse rate around 80 beats per

minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute.

Which of these actions should the nurse take?

)

Document the finding, as it is a normal finding at this time.

)

Contact the physician, as it indicates early DIC.

)

Contact the physician, as it is a first sign of postpartum eclampsia.

)

Obtain an order for a CBC, as it suggests postpartum anemia.

To decrease the pain associated with an episiotomy immediately after birth,

which action by the nurse would be most appropriate?

)

Offer warm blankets.

)

Encourage the woman to void.

)

Apply an ice pack to the site.

Offer a warm sitz bath.

To decrease the pain associated with an episiotomy immediately after birth,

which action by the nurse would be most appropriate?

)

Offer warm blankets.

)

Encourage the woman to void.

)

Apply an ice pack to the site.

)

Offer a warm sitz bath.

A postpartum client has a fourth-degree perineal laceration. The nurse would

expect which of the following medications to be ordered?

)

Ferrous sulfate (Feosol)

)

Methylergonovine (Methergine)

)

Docusate (Colace)

)

Bromocriptine (Parlodel)

Which statement would alert the nurse to the potential for impaired bonding

between mother and newborn?

)

You have your daddys eyes.

)

He looks like a frog to me.

)

Where did you get all that hair?

)

He seems to sleep a lot.

After a normal labor and birth, a client is discharged from the hospital 12 hours

later. When the community health nurse makes a home visit 2 days later, which

finding would alert the nurse to the need for further intervention?

)

Presence of lochia serosa

)

Frequent scant voidings

)

Fundus firm, below umbilicus

)

Milk filling in both breasts

A primipara client who is bottle feeding her baby begins to experience breast

engorgement on her third postpartum day. Which instruction would be most

appropriate to aid in relieving her discomfort?

)

Express some milk from your breasts every so often to relieve the distention.

)

Remove your bra to relieve the pressure on your sensitive nipples and breasts.

)

Apply ice packs to your breasts to reduce the amount of milk being produced.

)

Take several warm showers daily to stimulate the milk let-down reflex.

The nurse administers RhoGAM to an Rh-negative client after delivery of an

Rh-positive newborn based on the understanding that this drug will prevent her

from:

)

Becoming Rh positive

)

Developing Rh sensitivity

)

Developing AB antigens in her blood

Becoming pregnant with an Rh-positive fetus

Rh-positive newborn based on the understanding that this drug will prevent her

from:

)

Becoming Rh positive

)

Developing Rh sensitivity

)

Developing AB antigens in her blood

)

Becoming pregnant with an Rh-positive fetus

Which of the following factors in a clients history would alert the nurse to an

increased risk for postpartum hemorrhage?

)

Multiparity, age of mother, operative delivery

)

Size of placenta, small baby, operative delivery

)

Uterine atony, placenta previa, operative procedures

)

Prematurity, infection, length of labor

After teaching parents about their newborn, the nurse determines that the

teaching was successful when they identify the development of a close

emotional attraction to a newborn by parents during the first 30 to 60 minutes

after birth as which of the following?

)

Reciprocity

)

Engrossment

)

Bonding

)

Attachment

)

Engrossment

)

Bonding

)

Attachment

A nurse is working as part of a committee to establish policies to promote

bonding and attachment. Which practice would be least effective in achieving

this goal?

)

Allowing unlimited visiting hours on maternity units

)

Offering round-the-clock nursery care for all infants

)

Promoting rooming-in

)

Encouraging infant contact immediately after birth

When developing the plan of care for the parents of a newborn, the nurse

identifies interventions to promote bonding and attachment based on the

rationale that bonding and attachment are most supported by which measure?

)

Early parentinfant contact following birth

)

Expert medical care for the labor and birth

)

Good nutrition and prenatal care during pregnancy

)

Grandparent involvement in infant care after birth

A postpartum woman is having difficulty voiding for the first time after giving

birth. Which of the following would be least effective in helping to stimulate

voiding?

)

Pouring warm water over her perineal area

)

Having her hear the sound of water running nearby

A postpartum woman is having difficulty voiding for the first time after giving

birth. Which of the following would be least effective in helping to stimulate

voiding?

)

Pouring warm water over her perineal area

)

Having her hear the sound of water running nearby

)

Placing her hand in a basin of cool water

)

Standing her in the shower with the warm water on

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz

bath. Which of the following would be a priority?

)

Placing the call light within her reach

)

Teaching her how the sitz bath works

)

Telling her to use the sitz bath for 30 minutes

)

Cleaning the perineum with the peri-bottle

A nurse is reviewing the medical record of a postpartum client. The nurse

identifies that the woman is at risk for a postpartum infection based on which of

the following? (Select all that apply.)

)

History of diabetes

)

Labor of 12 hours

)

Rupture of membranes for 16 hours

)

Hemoglobin level 10 mg/dL

)

Placenta requiring manual extraction

)

History of diabetes

)

Labor of 12 hours

)

Rupture of membranes for 16 hours

)

Hemoglobin level 10 mg/dL

)

Placenta requiring manual extraction

A nurse is completing a postpartum assessment. Which finding would alert the

nurse to a potential problem?

)

Lochia rubra with a fleshy odor

)

Respiratory rate of 16 breaths per minute

)

Temperature of 101 F

)

Pain rating of 2 on a scale from 0 to 10

The nurse is assessing a postpartum clients lochia and finds that there is about a

4-inch stain on the perineal pad. The nurse documents this finding as which of

the following?

)

Scant

)

Light

)

Moderate

)

Large

)

Light

)

Moderate

)

Large

When reviewing the medical record of a postpartum client, the nurse notes that

the client has experienced a third-degree laceration. The nurse understands that

the laceration extends to which of the following?

)

Superficial structures above the muscle

)

Through the perineal muscles

)

Through the anal sphincter muscle

)

Through the anterior rectal wall

A nurse is observing a postpartum client interacting with her newborn and notes

that the mother is engaging with the newborn in the en face position. Which of

the following would the nurse be observing?

)

Mother placing the newborn next to bare breast.

)

Mother making eye-to-eye contact with the newborn

)

Mother gently stroking the newborns face

)

Mother holding the newborn upright at the shoulder

After teaching a group of students about risk factors associated with postpartum

hemorrhage, the instructor determines that the teaching was successful when the

students identify which of the following as a risk factor? (Select all that apply.)

)

Prolonged labor

)

Placenta previa

After teaching a group of students about risk factors associated with postpartum

hemorrhage, the instructor determines that the teaching was successful when the

students identify which of the following as a risk factor? (Select all that apply.)

)

Prolonged labor

)

Placenta previa

)

Null parity

)

Hydramnios

)

Labor augmentation

A postpartum woman who is breast-feeding tells the nurse that she is

experiencing nipple pain. Which of the following would be least appropriate for

the nurse to suggest?

)

Use of a mild analgesic about 1 hour before breast-feeding

)

Application of expressed breast milk to the nipples

)

Application of glycerin-based gel to the nipples

)

Reinstruction about proper latching-on technique

A nurse is developing a teaching plan for a postpartum woman who is breastfeeding

about sexuality and contraception. Which of the following would the

nurse most likely include? (Select all that apply.)

)

Resumption of sexual intercourse about two weeks after delivery

)

Possible experience of fluctuations in sexual interest

)

Use of a water-based lubricant to ease vaginal discomfort

)

Use of combined hormonal contraceptives for the first three weeks

about sexuality and contraception. Which of the following would the

nurse most likely include? (Select all that apply.)

)

Resumption of sexual intercourse about two weeks after delivery

)

Possible experience of fluctuations in sexual interest

)

Use of a water-based lubricant to ease vaginal discomfort

)

Use of combined hormonal contraceptives for the first three weeks

)

Possibility of increased breast sensitivity during sexual activity

After teaching a postpartum woman about breast-feeding, the nurse determines

that the teaching was successful when the woman states which of the following?

)

I should notice a decrease in abdominal cramping during breast-feeding.

)

I should wash my hands before starting to breast-feed.

)

The baby can be awake or sleepy when I start to feed him.

)

The babys mouth will open up once I put him to my breast.

A postpartum woman who is bottle-feeding her newborn asks the nurse, About

how much should my newborn drink at each feeding? The nurse responds by

saying that to feel satisfied, the newborn needs which amount at each feeding?

)

1 to 2 ounces

)

2 to 4 ounces

)

4 to 6 ounces

)

6 to 8 ounces

)

1 to 2 ounces

)

2 to 4 ounces

)

4 to 6 ounces

)

6 to 8 ounces

A nurse is observing a postpartum woman and her partner interact with the their

newborn. The nurse determines that the parents are developing parental

attachment with their newborn when they demonstrate which of the following?

(Select all that apply.)

)

Frequently ask for the newborn to be taken from the room

)

Identify common features between themselves and the newborn

)

Refer to the newborn as having a monkey-face

)

Make direct eye contact with the newborn

)

Refrain from checking out the newborns features

After reviewing information about postpartum blues, a group of students

demonstrate understanding when they state which of the following about this

condition?

)

Postpartum blues is a long-term emotional disturbance.

)

Sleep usually helps to resolve the blues.

)

The mother loses contact with reality.

)

Extended psychotherapy is needed for treatment.

)

Sleep usually helps to resolve the blues.

)

The mother loses contact with reality.

)

Extended psychotherapy is needed for treatment.

Chapter 17 Newborn Transitioning

When explaining how a newborn adapts to extrauterine life, the nurse would

describe which body systems as undergoing the most rapid changes?

)

Gastrointestinal and hepatic

)

Urinary and hematologic

)

Respiratory and cardiovascular

)

Neurological and integumentary

A new mother reports that her newborn often spits up after feeding. Assessment

reveals regurgitation. The nurse responds integrating understanding that this

most likely is due to which of the following?

)

Placing the newborn prone after feeding

)

Limited ability of digestive enzymes

)

Underdeveloped pyloric sphincter

)

Relaxed cardiac sphincter

)

Limited ability of digestive enzymes

)

Underdeveloped pyloric sphincter

)

Relaxed cardiac sphincter

After teaching a class about hepatic system adaptations after birth, the instructor

determines that the teaching was successful when the class identifies which of

the following as the process of changing bilirubin from a fat-soluble product to a

water-soluble product?

)

Hemolysis

)

Conjugation

)

Jaundice

)

Hyperbilirubinemia

Twenty minutes after birth, a baby begins to move his head from side to side,

making eye contact with the mother, and pushes his tongue out several times.

The nurse interprets this as indicating which of the following?

)

A good time to initiate breast-feeding

)

The period of decreased responsiveness preceding sleep

)

The need to be alert for gagging and vomiting

)

Evidence that the newborn is becoming chilled

The nurse institutes measure to maintain thermoregulation based on the

understanding that newborns have limited ability to regulate body temperature

because they:

)

Have a smaller body surface compared to body mass

)

Lose more body heat when they sweat than adults

)

Have an abundant amount of subcutaneous fat all over

)

Are unable to shiver effectively to increase heat production

A new mother is changing the diaper of her 20-hour-old newborn and asks why

the stool is almost black. Which response by the nurse would be most

appropriate?

)

You probably took iron during your pregnancy.

)

This is meconium stool, normal for a newborn.

)

Ill take a sample and check it for possible bleeding.

)

This is unusual and I need to report this.

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to

awaken. The nurse explains that this behavior indicates which of the following?

)

Normal progression of behavior

)

Probable hypoglycemia

)

Physiological abnormality

)

Inadequate oxygenation

A client expresses concern that her 2-hour-old newborn is sleepy and difficult to

awaken. The nurse explains that this behavior indicates which of the following?

)

Normal progression of behavior

)

Probable hypoglycemia

)

Physiological abnormality

)

Inadequate oxygenation

After the birth of a newborn, which of the following would the nurse do first to

assist in thermoregulation?

)

Dry the newborn thoroughly.

)

Put a hat on the newborns head.

)

Check the newborns temperature.

)

Wrap the newborn in a blanket.

Assessment of a newborn reveals rhythmic spontaneous movements. The nurse

interprets this as indicating:

)

Habituation

)

Motor maturity

)

Orientation

)

Social behaviors

After teaching new parents about the sensory capabilities of their newborn, the

nurse determines that the teaching was successful when they identify which

sense as being the least mature?

)

Hearing

)

Touch

)

Taste

)

Vision

The nurse places a warmed blanket on the scale when weighing a newborn. The

nurse does so to minimize heat loss via which mechanism?

)

Evaporation

)

Conduction

)

Convection

)

Radiation

Which of the following would alert the nurse to the possibility of respiratory

distress in a newborn?

)

Symmetrical chest movements

)

Periodic breathing

)

Respirations of 40 breaths/minute

Sternal retractions

distress in a newborn?

)

Symmetrical chest movements

)

Periodic breathing

)

Respirations of 40 breaths/minute

)

Sternal retractions

A nurse is counseling a mother about the immunologic properties of breast milk.

The nurse integrates knowledge of immunoglobulins, emphasizing that breast

milk is a major source of which immunoglobulin?

)

IgA

)

IgG

)

IgM

)

IgE

The nurse is teaching a group of students about the similarities and differences

between newborn skin and adult skin. Which statement by the group indicates

that additional teaching is needed?

)

The newborns skin and that of an adult are similar in thickness.

)

The lipid composition of the skin of a newborn and adult is about the same.

)

Skin development in the newborn is complete at birth.

)

The newborn has more fibrils connecting the dermis and epidermis.

)

The lipid composition of the skin of a newborn and adult is about the same.

)

Skin development in the newborn is complete at birth.

)

The newborn has more fibrils connecting the dermis and epidermis.

A nurse is developing a teaching plan for the parents of a newborn. When

describing the neurologic development of a newborn to his parents, the nurse

would explain that the development occurs in which fashion?

)

Head-to-toe

)

Lateral-to-medial

)

Outward-to-inward

)

Distal-to-caudal

The nurse is assessing the respirations of several newborns. The nurse would

notify the health care provider for the newborn with which respiratory rate at

rest?

)

38 breaths per minute

)

46 breaths per minute

)

54 breaths per minute

)

68 breaths per minute

A new mother asks the nurse, Why has my baby lost weight since he was born?

The nurse integrates knowledge of which of the following when responding to

the new mother?

)

Insufficient calorie intake

)

Shift of water from extracellular space to intracellular space

A new mother asks the nurse, Why has my baby lost weight since he was born?

The nurse integrates knowledge of which of the following when responding to

the new mother?

)

Insufficient calorie intake

)

Shift of water from extracellular space to intracellular space

)

Increase in stool passage

)

Overproduction of bilirubin

The nurse observes the stool of a newborn who has begun to breast-feed. Which

of the following would the nurse expect to find?

)

Greenish black, tarry stool

)

Yellowish-brown, seedy stool

)

Yellow-gold, stringy stool

)

Yellowish-green, pasty stool

A nurse is assessing a newborn who is about 4 hours old. The nurse would

expect this newborn to exhibit which of the following? (Select all that apply.)

)

Sleeping

)

Interest in environmental stimuli

)

Passage of meconium

)

Difficulty arousing the newborn

)

Spontaneous Moro reflexes

)

Sleeping

)

Interest in environmental stimuli

)

Passage of meconium

)

Difficulty arousing the newborn

)

Spontaneous Moro reflexes

A nurse is assessing a newborn and observes the newborn moving his head and

eyes toward a loud sound. The nurse interprets this as which of the following?

)

Habituation

)

Motor maturity

)

Social behavior

)

Orientation

A newborn is experiencing cold stress. Which of the following would the nurse

expect to assess? (Select all that apply.)

)

Respiratory distress

)

Decreased oxygen needs

)

Hypoglycemia

)

Metabolic alkalosis

)

Jaundice

)

Decreased oxygen needs

)

Hypoglycemia

)

Metabolic alkalosis

)

Jaundice

A group of nursing students are reviewing the changes in the newborns lungs

that must occur to maintain respiratory function. The students demonstrate

understanding of this information when they identify which of the following as

the first event?

)

Expansion of the lungs

)

Increased pulmonary blood flow

)

Initiation of respiratory movement

)

Redistribution of cardiac output

A nurse is reviewing the laboratory test results of a newborn. Which result

would the nurse identify as a cause for concern?

)

Hemoglobin 19 g/dL

)

Platelets 75,000/uL

)

White blood cells 20,000/mm3

)

Hematocrit 52%

A nursing instructor is preparing a class on newborn adaptations. When

describing the change from fetal to newborn circulation, which of the following

would the instructor most likely include? (Select all that apply.)

)

Decrease in right atrial pressure leads to closure of the foramen ovale.

)

Increase in oxygen levels leads to a decrease in systemic vascular resistance.

)

Onset of respirations leads to a decrease in pulmonary vascular resistance.

)

Increase in pressure in the left atrium results from increases in pulmonary blood

flow.

)

Closure of the ductus venosus eventually forces closure of the ductus arteriosus.

A nursing student is preparing a presentation on minimizing heat loss in the

newborn. Which of the following would the student include as a measure to

prevent heat loss through convection?

)

Placing a cap on a newborns head

)

Working inside an isolette as much as possible.

)

Placing the newborn skin-to-skin with the mother

)

Using a radiant warmer to transport a newborn

After teaching a group of nursing students about a neutral thermal environment,

the instructor determines that the teaching was successful when the students

identify which of the following as the newborns primary method of heat

production?

)

Convection

)

Nonshivering thermogenesis

After teaching a group of nursing students about a neutral thermal environment,

the instructor determines that the teaching was successful when the students

identify which of the following as the newborns primary method of heat

production?

)

Convection

)

Nonshivering thermogenesis

)

Cold stress

)

Bilirubin conjugation

While observing the interaction between a newborn and his mother, the nurse

notes the newborn nestling into the arms of his mother. The nurse identifies this

behavior as which of the following?

)

Habituation

)

Self-quieting ability

)

Social behaviors

)

Orientation

Chapter 18 Nursing Management of the Newborn

Prior to discharging a 24-hour-old newborn, the nurse assesses her respiratory

status. Which of the following would the nurse expect to assess?

)

Respiratory rate 45, irregular

)

Costal breathing pattern

)

Nasal flaring, rate 65

)

Crackles on auscultation

The nurse encourages the mother of a healthy newborn to put the newborn to the

breast immediately after birth for which reason?

)

To aid in maturing the newborns sucking reflex

)

To encourage the development of maternal antibodies

)

To facilitate maternalinfant bonding

)

To enhance the clearing of the newborns respiratory passages

When making a home visit, the nurse observes a newborn sleeping on his back

in a bassinet. In one corner of the bassinet is a soft stuffed animal and at the

other end is a bulb syringe. The nurse determines that the mother needs

additional teaching because of which of the following?

)

The newborn should not be sleeping on his back.

)

Stuffed animals should not be in areas where infants sleep.

)

The bulb syringe should not be kept in the bassinet.

)

This newborn should be sleeping in a crib.

other end is a bulb syringe. The nurse determines that the mother needs

additional teaching because of which of the following?

)

The newborn should not be sleeping on his back.

)

Stuffed animals should not be in areas where infants sleep.

)

The bulb syringe should not be kept in the bassinet.

)

This newborn should be sleeping in a crib.

Assessment of a newborn reveals a heart rate of 180 beats/minute. To determine

whether this finding is a common variation rather than a sign of distress, what

else does the nurse need to know?

)

How many hours old is this newborn?

)

How long ago did this newborn eat?

)

What was the newborns birth weight?

)

Is acrocyanosis present?

Just after delivery, a newborns axillary temperature is 94 C. What action would

be most appropriate?

)

Assess the newborns gestational age.

)

Rewarm the newborn gradually.

)

Observe the newborn every hour.

)

Notify the physician if the temperature goes lower.

The parents of a newborn become concerned when they notice that their baby

seems to stop breathing for a few seconds. After confirming the parents findings

by observing the newborn, which of the following actions would be most

appropriate?

)

Notify the health care provider immediately.

)

Assess the newborn for signs of respiratory distress.

)

Reassure the parents that this is an expected pattern.

)

Tell the parents not to worry since his color is fine.

When assessing a newborn 1 hour after birth, the nurse measures an axillary

temperature of 95.8 F, an apical pulse of 114 beats/minute, and a respiratory rate

of 60 breaths/minute. Which nursing diagnosis takes highest priority?

)

Hypothermia related to heat loss during birthing process

)

Impaired parenting related to addition of new family member

)

Risk for deficient fluid volume related to insensible fluid loss

)

Risk for infection related to transition to extrauterine environment

The nurse places a newborn with jaundice under the phototherapy lights in the

nursery to achieve which goal?

)

Prevent cold stress

)

Increase surfactant levels in the lungs

)

Promote respiratory stability

The nurse places a newborn with jaundice under the phototherapy lights in the

nursery to achieve which goal?

)

Prevent cold stress

)

Increase surfactant levels in the lungs

)

Promote respiratory stability

)

Decrease the serum bilirubin level

The nurse completes the initial assessment of a newborn. Which finding would

lead the nurse to suspect that the newborn is experiencing difficulty with

oxygenation?

)

Respiratory rate of 54 breaths/minute

)

Abdominal breathing

)

Nasal flaring

)

Acrocyanosis

During a physical assessment of a newborn, the nurse observes bluish markings

across the newborns lower back. The nurse documents this finding as which of

the following?

)

Milia

)

Mongolian spots

)

Stork bites

)

Birth trauma

)

Mongolian spots

)

Stork bites

)

Birth trauma

While making rounds in the nursery, the nurse sees a 6-hour-old baby girl

gagging and turning bluish. Which of the following would the nurse do first?

)

Alert the physician stat and turn the newborn to her right side.

)

Administer oxygen via facial mask by positive pressure.

)

Lower the newborns head to stimulate crying.

)

Aspirate the oral and nasal pharynx with a bulb syringe.

While performing a physical assessment of a newborn boy, the nurse notes

diffuse edema of the soft tissues of his scalp that crosses suture lines. The nurse

documents this finding as:

)

Molding

)

Microcephaly

)

Caput succedaneum

)

Cephalhematoma

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a

clunk when Ortolanis maneuver is performed. Which of the following would the

nurse suspect?

)

Slipping of the periosteal joint

)

Developmental hip dysplasia

Assessment of a newborn reveals uneven gluteal (buttocks. skin creases and a

clunk when Ortolanis maneuver is performed. Which of the following would the

nurse suspect?

)

Slipping of the periosteal joint

)

Developmental hip dysplasia

)

Normal newborn variation

)

Overriding of the pelvic bone

The nurse strokes the lateral sole of the newborns foot from the heel to the ball

of the foot when evaluating which reflex?

)

Babinski

)

Tonic neck

)

Stepping

)

Plantar grasp

The nurse administers vitamin K intramuscularly to the newborn based on

which of the following rationales?

)

Stop Rh sensitization

)

Increase erythopoiesis

)

Enhance bilirubin breakdown

)

Promote blood clotting

)

Stop Rh sensitization

)

Increase erythopoiesis

)

Enhance bilirubin breakdown

)

Promote blood clotting

The nurse is assessing the skin of a newborn and notes a rash on the newborns

face, and chest. The rash consists of small papules and is scattered with no

pattern. The nurse interprets this finding as which of the following?

)

Harlequin sign

)

Nevus flammeus

)

Erythema toxicum

)

Port wine stain

After teaching a group of nursing students about variations in newborn head size

and appearance, the instructor determines that the teaching was successful when

the students identify which of the following as a normal variation? (Select all

that apply.)

)

Cephalhematoma

)

Molding

)

Closed fontanels

)

Caput succedaneum

)

Posterior fontanel diameter 1.5 cm

)

Closed fontanels

)

Caput succedaneum

)

Posterior fontanel diameter 1.5 cm

The nurse is assessing a newborns eyes. Which of the following would the nurse

identify as normal? (Select all that apply.)

)

Slow blink response

)

Able to track object to midline

)

Transient deviation of the eyes

)

Involuntary repetitive eye movement

)

Absent red reflex

Assessment of a newborns head circumference reveals that it is 34 cm. The

nurse would suspect that this newborns chest circumference would be:

)

30 cm

)

32 cm

)

34 cm

)

36 cm

The nurse is auscultating a newborns heart and places the stethoscope at the

point of maximal impulse at which location?

)

Just superior to the nipple, at the midsternum

)

Lateral to the midclavicular line at the fourth intercostal space

)

At the fifth intercostal space to the left of the sternum

)

Directly adjacent to the sternum at the second intercostals space

The nurse is inspecting the external genitalia of a male newborn. Which of the

following would alert the nurse to a possible problem?

)

Limited rugae

)

Large scrotum

)

Palpable testes in scrotal sac

)

Absence of engorgement

When assessing a newborns reflexes, the nurse strokes the newborns cheek and

the newborn turns toward the side that was stroked and begins sucking. The

nurse documents which reflex as being positive?

)

Palmar grasp reflex

)

Tonic neck reflex

)

Moro reflex

Rooting reflex

the newborn turns toward the side that was stroked and begins sucking. The

nurse documents which reflex as being positive?

)

Palmar grasp reflex

)

Tonic neck reflex

)

Moro reflex

)

Rooting reflex

A nurse is teaching new parents about bathing their newborn. The nurse

determines that the teaching was successful when the parents state which of the

following?

)

We can put a tiny bit of lotion on his skin and then rub it in gently.

)

We should avoid using any kind of baby powder.

)

We need to bathe him at least four to five times a week.

)

We should clean his eyes after washing his face and hair.

A new mother who is breast-feeding her newborn asks the nurse, How will I

know if my baby is drinking enough? Which response by the nurse would be

most appropriate?

)

If he seems content after feeding, that should be a sign.

)

Make sure he drinks at least 5 minutes on each breast.

)

He should wet between 6 to 12 diapers each day.

)

If his lips are moist, then hes okay.

)

Make sure he drinks at least 5 minutes on each breast.

)

He should wet between 6 to 12 diapers each day.

)

If his lips are moist, then hes okay.

A nurse is teaching postpartum client and her partner about caring for their

newborns umbilical cord site. Which statement by the parents indicates a need

for additional teaching?

)

We can put him in the tub to bathe him once the cord falls off and is healed.

)

The cord stump should change from brown to yellow.

)

Exposing the stump to the air helps it to dry.

)

We need to call the doctor if we notice a funny odor.

While changing a female newborns diaper, the nurse observes a mucus-like,

slightly bloody vaginal discharge. Which of the following would the nurse do

next?

)

Document this as pseudomenstruation

)

Notify the practitioner immediately

)

Obtain a culture of the discharge

)

Inspect for engorgement

A nursing instructor is describing the advantages and disadvantages associated

with newborn circumcision to a group of nursing students. Which statement by

the students indicates effective teaching?

)

Sexually transmitted infections are more common in circumcised males.

)

The rate of penile cancer is less for circumcised males.

A nursing instructor is describing the advantages and disadvantages associated

with newborn circumcision to a group of nursing students. Which statement by

the students indicates effective teaching?

)

Sexually transmitted infections are more common in circumcised males.

)

The rate of penile cancer is less for circumcised males.

)

Urinary tract infections are more easily treated in circumcised males.

)

Circumcision is a risk factor for acquiring HIV infection.

A newborn is scheduled to undergo a screening test for phenylketonuria (PKU).

The nurse prepares to obtain the blood sample from the newborns:

)

Finger

)

Heel

)

Scalp vein

)

Umbilical vein

Assessment of a newborn reveals transient tachypnea. The nurse reviews the

newborns medical record. Which of the following would the nurse be least

likely to identify as a risk factor for this condition?

)

Cesarean birth

)

Shortened labor

)

Central nervous system depressant during labor

)

Maternal asthma

)

Cesarean birth

)

Shortened labor

)

Central nervous system depressant during labor

)

Maternal asthma

A nurse is providing teaching to a new mother about her newborns nutritional

needs. Which of the following would the nurse be most likely to include in the

teaching? (Select all that apply.)

)

Supplementing with iron if the woman is breast-feeding

)

Providing supplemental water intake with feedings

)

Feeding the newborn every 2 to 4 hours during the day

)

Burping the newborns frequently throughout each feeding

)

Using feeding time for promoting closeness

Chapter 19 Nursing Management of Pregnancy at Risk: Pregnancy-Related Complications

After teaching a woman who has had an evacuation for a hydatidiform mole

(molar pregnancy. about her condition, which of the following statements

indicates that the nurses teaching was successful?

)

I will be sure to avoid getting pregnant for at least 1 year.

)

My intake of iron will have to be closely monitored for 6 months.

)

My blood pressure will continue to be increased for about 6 more months.

)

I wont use my birth control pills for at least a year or two.

Which of the following findings on a prenatal visit at 10 weeks might lead the

nurse to suspect a hydatidiform mole?

)

Complaint of frequent mild nausea

)

Blood pressure of 120/84 mm Hg

)

History of bright red spotting 6 weeks ago

)

Fundal height measurement of 18 cm

A client is diagnosed with gestational hypertension and is receiving magnesium

sulfate. Which finding would the nurse interpret as indicating a therapeutic level

of medication?

)

Urinary output of 20 mL per hour

)

Respiratory rate of 10 breaths/minute

Deep tendons reflexes 2+

A client is diagnosed with gestational hypertension and is receiving magnesium

sulfate. Which finding would the nurse interpret as indicating a therapeutic level

of medication?

)

Urinary output of 20 mL per hour

)

Respiratory rate of 10 breaths/minute

)

Deep tendons reflexes 2+

)

Difficulty in arousing

Upon entering the room of a client who has had a spontaneous abortion, the

nurse observes the client crying. Which of the following responses by the nurse

would be most appropriate?

)

Why are you crying?

)

Will a pill help your pain?

)

Im sorry you lost your baby.

)

A baby still wasnt formed in your uterus.

Which of the following data on a clients health history would the nurse identify

as contributing to the clients risk for an ectopic pregnancy?

)

Use of oral contraceptives for 5 years

)

Ovarian cyst 2 years ago

)

Recurrent pelvic infections

)

Heavy, irregular menses

)

Ovarian cyst 2 years ago

)

Recurrent pelvic infections

)

Heavy, irregular menses

In a woman who is suspected of having a ruptured ectopic pregnancy, the nurse

would expect to assess for which of the following as a priority?

)

Hemorrhage

)

Jaundice

)

Edema

)

Infection

Which of the following findings would the nurse interpret as suggesting a

diagnosis of gestational trophoblastic disease?

)

Elevated hCG levels, enlarged abdomen, quickening

)

Vaginal bleeding, absence of FHR, decreased hPL levels

)

Visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen

)

Gestational hypertension, hyperemesis gravidarum, absence of FHR

It is determined that a clients blood Rh is negative and her partners is positive.

To help prevent Rh isoimmunization, the nurse anticipates that the client will

receive RhoGAM at which time?

)

At 34 weeks gestation and immediately before discharge

)

24 hours before delivery and 24 hours after delivery

)

In the first trimester and within 2 hours of delivery

It is determined that a clients blood Rh is negative and her partners is positive.

To help prevent Rh isoimmunization, the nurse anticipates that the client will

receive RhoGAM at which time?

)

At 34 weeks gestation and immediately before discharge

)

24 hours before delivery and 24 hours after delivery

)

In the first trimester and within 2 hours of delivery

)

At 28 weeks gestation and again within 72 hours after delivery

The nurse is developing a plan of care for a woman who is pregnant with twins.

The nurse includes interventions focusing on which of the following because of

the womans increased risk?

)

Oligohydramnios

)

Preeclampsia

)

Post-term labor

)

Chorioamnionitis

A woman hospitalized with severe preeclampsia is being treated with

hydralazine to control blood pressure. Which of the following would the lead

the nurse to suspect that the client is having an adverse effect associated with

this drug?

)

Gastrointestinal bleeding

)

Blurred vision

)

Tachycardia

)

Sweating

)

Gastrointestinal bleeding

)

Blurred vision

)

Tachycardia

)

Sweating

After reviewing a clients history, which factor would the nurse identify as

placing her at risk for gestational hypertension?

)

Mother had gestational hypertension during pregnancy.

)

Client has a twin sister.

)

Sister-in-law had gestational hypertension.

)

This is the clients second pregnancy.

A client with hyperemesis gravidarum is admitted to the facility after being

cared for at home without success. Which of the following would the nurse

expect to include in the clients plan of care?

)

Clear liquid diet

)

Total parenteral nutrition

)

Nothing by mouth

)

Administration of labetalol

The nurse is reviewing the laboratory test results of a pregnant client. Which

one of the following findings would alert the nurse to the development of

HELLP syndrome?

)

Hyperglycemia

)

Elevated platelet count

)

Leukocytosis

)

Elevated liver enzymes

Which of the following would the nurse have readily available for a client who

is receiving magnesium sulfate to treat severe preeclampsia?

)

Calcium gluconate

)

Potassium chloride

)

Ferrous sulfate

)

Calcium carbonate

Which assessment finding would lead the nurse to suspect infection as the

cause of a clients PROM?

)

Yellow-green fluid

)

Blue color on Nitrazine testing

)

Ferning

Foul odor

cause of a clients PROM?

)

Yellow-green fluid

)

Blue color on Nitrazine testing

)

Ferning

)

Foul odor

While assessing a pregnant woman, the nurse suspects that the client may be at

risk for hydramnios based on which of the following? (Select all that apply.)

)

History of diabetes

)

Complaints of shortness of breath

)

Identifiable fetal parts on abdominal palpation

)

Difficulty obtaining fetal heart rate

)

Fundal height below that for expected gestataional age

After teaching a group of nursing students about the possible causes of

spontaneous abortion, the instructor determines that the teaching was successful

when the students identify which of the following as the most common cause of

first trimester abortions?

)

Maternal disease

)

Cervical insufficiency

)

Fetal genetic abnormalities

)

Uterine fibroids

)

Maternal disease

)

Cervical insufficiency

)

Fetal genetic abnormalities

)

Uterine fibroids

A pregnant woman is admitted with premature rupture of the membranes. The

nurse is assessing the woman closely for possible infection. Which of the

following would lead the nurse to suspect that the woman is developing an

infection? (Select all that apply.)

)

Fetal bradycardia

)

Abdominal tenderness

)

Elevated maternal pulse rate

)

Decreased C-reactive protein levels

)

Cloudy malodorous fluid

A nurse is teaching a pregnant woman with preterm premature rupture of

membranes who is about to be discharged home about caring for herself. Which

statement by the woman indicates a need for additional teaching?

)

I need to keep a close eye on how active my baby is each day.

)

I need to call my doctor if my temperature increases.

)

Its okay for my husband and me to have sexual intercourse.

)

I can shower but I shouldnt take a tub bath.

)

I need to call my doctor if my temperature increases.

)

Its okay for my husband and me to have sexual intercourse.

)

I can shower but I shouldnt take a tub bath.

A nurse is assessing a pregnant woman with gestational hypertension. Which of

the following would lead the nurse to suspect that the client has developed

severe preeclampsia?

)

Urine protein 300 mg/24 hours

)

Blood pressure 150/96 mm Hg

)

Mild facial edema

)

Hyperreflexia

A nurse suspects that a pregnant client may be experiencing abruption placenta

based on assessment of which of the following? (Select all that apply.)

)

Dark red vaginal bleeding

)

Insidious onset

)

Absence of pain

)

Rigid uterus

)

Absent fetal heart tones

The health care provider orders PGE2 for a woman to help evacuate the uterus

following a spontaneous abortion. Which of the following would be most

important for the nurse to do?

)

Use clean technique to administer the drug.

)

Keep the gel cool until ready to use.

)

Maintain the client for hour after administration.

)

Administer intramuscularly into the deltoid area.

A nursing student is reviewing an article about preterm premature rupture of

membranes. Which of the following would the student expect to find as factor

placing a woman at high risk for this condition? (Select all that apply.)

)

High body mass index

)

Urinary tract infection

)

Low socioeconomic status

)

Single gestations

)

Smoking

A woman with placenta previa is being treated with expectant management. The

woman and fetus are stable. The nurse is assessing the woman for possible

discharge home. Which statement by the woman would suggest to the nurse that

home care might be inappropriate?

)

My mother lives next door and can drive me here if necessary.

)

I have a toddler and preschooler at home who need my attention.

A woman with placenta previa is being treated with expectant management. The

woman and fetus are stable. The nurse is assessing the woman for possible

discharge home. Which statement by the woman would suggest to the nurse that

home care might be inappropriate?

)

My mother lives next door and can drive me here if necessary.

)

I have a toddler and preschooler at home who need my attention.

)

I know to call my health care provider right away if I start to bleed again.

)

I realize the importance of following the instructions for my care.

A woman with hyperemesis gravidarum asks the nurse about suggestions to

minimize nausea and vomiting. Which suggestion would be most appropriate

for the nurse to make?

)

Make sure that anything around your waist is quite snug.

)

Try to eat three large meals a day with less snacking.

)

Drink fluids in between meals rather than with meals.

)

Lie down for about an hour after you eat

A woman with gestational hypertension experiences a seizure. Which of the

following would be the priority?

)

Fluid replacement

)

Oxygenation

)

Control of hypertension

)

Delivery of the fetus

)

Fluid replacement

)

Oxygenation

)

Control of hypertension

)

Delivery of the fetus

A woman is receiving magnesium sulfate as part of her treatment for severe

preeclampsia. The nurse is monitoring the womans serum magnesium levels.

Which level would the nurse identify as therapeutic?

)

3.3 mEq/L

)

6.1 mEq/L

)

8.4 mEq/L

)

10.8 mEq/L

Chapter 20 Nursing Management Pregnancy at Risk: Health Conditions & Vulnerable Populations

The nurse is teaching a pregnant woman with type 1 diabetes about her diet

during pregnancy. Which client statement indicates that the nurses teaching was

successful?

)

Ill basically follow the same diet that I was following before I became pregnant.

)

Because I need extra protein, Ill have to increase my intake of milk and meat.

The nurse is teaching a pregnant woman with type 1 diabetes about her diet

during pregnancy. Which client statement indicates that the nurses teaching was

successful?

)

Ill basically follow the same diet that I was following before I became pregnant.

)

Because I need extra protein, Ill have to increase my intake of milk and meat.

)

Pregnancy affects insulin production, so Ill need to make adjustments in my diet.

)

Ill adjust my diet and insulin based on the results of my urine tests for glucose.

A nurse is developing a program for pregnant women with diabetes about

reducing complications. Which factor would the nurse identify as being most

important in helping to reduce the maternal/fetal/neonatal complications

associated with pregnancy and diabetes?

)

Stability of the womans emotional and psychological status

)

Degree of glycemic control achieved during the pregnancy

)

Evaluation of retinopathy by an ophthalmologist

)

Blood urea nitrogen level (BUN. within normal limits

Because a pregnant clients diabetes has been poorly controlled throughout her

pregnancy, the nurse would be alert for which of the following in the neonate at

birth?

)

Macrosomia

)

Hyperglycemia

)

Low birth weight

)

Hypobilirubinemia

)

Macrosomia

)

Hyperglycemia

)

Low birth weight

)

Hypobilirubinemia

A woman with diabetes is considering becoming pregnant. She asks the nurse

whether she will be able to take oral hypoglycemics when she is pregnant. The

nurses response is based on the understanding that oral hypoglycemics:

)

Can be used as long as they control serum glucose levels

)

Can be taken until the degeneration of the placenta occurs

)

Are usually suggested primarily for women who develop gestational diabetes

)

Show promising results but more studies are needed to confirm their

effectiveness

A 10-week pregnant woman with diabetes has a glycosylated hemoglobin

(HbA1C. level of 13%. At this time the nurse should be most concerned about

which of the following possible fetal outcomes?

)

Congenital anomalies

)

Incompetent cervix

)

Placenta previa

)

Abruptio placentae

After teaching a group of students about the use of antiretroviral agents in

pregnant women who are HIV-positive, the instructor determines that the

teaching was successful when the group identifies which of the following as the

underlying rationale?

)

Reduction in viral loads in the blood

)

Treatment of opportunistic infections

)

Adjunct therapy to radiation and chemotherapy

)

Can cure acute HIV/AIDS infections

Assessment of a pregnant woman and her fetus reveals tachycardia and

hypertension. There is also evidence suggesting vasoconstriction. The nurse

would question the woman about use of which substance?

)

Marijuana

)

Alcohol

)

Heroin

)

Cocaine

When teaching a class of pregnant women about the effects of substance abuse

during pregnancy, which of the following would the nurse most likely include?

)

Low-birth-weight infants

)

Excessive weight gain

)

Higher pain tolerance

Longer gestational periods

When teaching a class of pregnant women about the effects of substance abuse

during pregnancy, which of the following would the nurse most likely include?

)

Low-birth-weight infants

)

Excessive weight gain

)

Higher pain tolerance

)

Longer gestational periods

A client who is HIV-positive is in her second trimester and remains

asymptomatic. She voices concern about her newborns risk for the infection.

Which of the following statements by the nurse would be most appropriate?

)

Youll probably have a cesarean birth to prevent exposing your newborn.

)

Antibodies cross the placenta and provide immunity to the newborn.

)

Wait until after the infant is born and then something can be done.

)

Antiretroviral medications are available to help reduce the risk of transmission.

When assessing a pregnant woman with heart disease throughout the antepartal

period, the nurse would be especially alert for signs and symptoms of cardiac

decompensation at which time?

)

16 to 20 weeks gestation

)

20 to 24 weeks gestation

)

24 to 28 weeks gestation

)

28 to 32 weeks gestation

)

20 to 24 weeks gestation

)

24 to 28 weeks gestation

)

28 to 32 weeks gestation

When preparing a schedule of follow-up visits for a pregnant woman with

chronic hypertension, which of the following would be most appropriate?

)

Monthly visits until 32 weeks, then bi-monthly visits

)

Bi-monthly visits until 28 weeks, then weekly visits

)

Monthly visits until 20 weeks, then bi-monthly visits

)

Bi-monthly visits until 36 weeks, then weekly visits

Which medication would the nurse question if ordered to control a pregnant

womans asthma?

)

Budesonide

)

Albuterol

)

Salmeterol

)

Oral prednisone

After teaching a pregnant woman with iron deficiency anemia about her

prescribed iron supplement, which statement indicates successful teaching?

)

I should take my iron with milk.

)

I should avoid drinking orange juice.

After teaching a pregnant woman with iron deficiency anemia about her

prescribed iron supplement, which statement indicates successful teaching?

)

I should take my iron with milk.

)

I should avoid drinking orange juice.

)

I need to eat foods high in fiber.

)

Ill call the doctor if my stool is black and tarry.

A nurse is providing care to several pregnant women at the clinic. The nurse

would screen for group B streptococcus infection in a client at:

)

16 weeks gestation

)

28 week gestation

)

32 weeks gestation

)

36 weeks gestation

The nurse is assessing a newborn of a woman who is suspected of abusing

alcohol. Which newborn finding would provide additional evidence to support

this suspicion?

)

Wide large eyes

)

Thin upper lip

)

Protruding jaw

)

Elongated nose

)

Wide large eyes

)

Thin upper lip

)

Protruding jaw

)

Elongated nose

After teaching a group of nursing students about the impact of pregnancy on the

older woman, the instructor determines that the teaching was successful when

the students state which of the following?

)

The majority of women who become pregnant over age 35 experience

complications.

)

Women over the age of 35 who become pregnant require a specialized type of

assessment.

)

Women over age 35 and are pregnant have an increased risk for spontaneous

abortions.

)

Women over age 35 are more likely to have substance abuse problems.

A group of students are reviewing information about sexually transmitted

infections and their effect on pregnancy. The students demonstrate

understanding of the information when they identify which infection as being

responsible for ophthalmia neonatorum?

)

Syphilis

)

Gonorrhea

)

Chlamydia

)

HPV

A nurse is preparing a presentation for a group of young adult pregnant women

about common infections and their effect on pregnancy. When describing the

infections, which infection would the nurse include as the most common

congenital and perinatal viral infection in the world?

)

Rubella

)

Hepatitis B

)

Cytomegalovirus

)

Parvovirus B19

A pregnant woman asks the nurse, Im a big coffee drinker. Will the caffeine in

my coffee hurt my baby? Which response by the nurse would be most

appropriate?

)

The caffeine in coffee has been linked to birth defects.

)

Caffeine has been shown to cause growth restriction in the fetus.

)

Caffeine is a stimulant and needs to be avoided completely.

)

If you keep your intake to less than 300 mg/day, you should be okay.

A neonate born to a mother who was abusing heroin is exhibiting signs and

symptoms of withdrawal. Which of the following would the nurse assess?

(Select all that apply.)

)

Low whimpering cry

)

Hypertonicity

)

Lethargy

symptoms of withdrawal. Which of the following would the nurse assess?

(Select all that apply.)

)

Low whimpering cry

)

Hypertonicity

)

Lethargy

)

Excessive sneezing

)

Overly vigorous sucking

)

Tremors

A nurse has been invited to speak at a local high school about adolescent

pregnancy. When developing the presentation, the nurse would incorporate

information related to which of the following? (Select all that apply.)

)

Peer pressure to become sexually active

)

Rise in teen birth rates over the years.

)

Latinas as having the highest teen birth rate

)

Loss of self-esteem as a major impact

)

Majority of teen pregnancies in the 1517-year-old age group

A nurse is counseling a pregnant woman with rheumatoid arthritis about

medications that can be used during pregnancy. Which drug would the nurse

emphasize as being contraindicated at this time?

)

Hydroxychloroquine

)

Nonsteroidal anti-inflammatory drug

)

Glucocorticoid

A nurse is counseling a pregnant woman with rheumatoid arthritis about

medications that can be used during pregnancy. Which drug would the nurse

emphasize as being contraindicated at this time?

)

Hydroxychloroquine

)

Nonsteroidal anti-inflammatory drug

)

Glucocorticoid

)

Methotrexate

A nurse is preparing a teaching program for a group of pregnant women about

preventing infections during pregnancy. When describing measures for

preventing cytomegalovirus infection, which of the following would the nurse

most likely include?

)

Frequent handwashing

)

Immunization

)

Prenatal screening

)

Antibody titer screening

A pregnant woman tests positive for HBV. Which of the following would the

nurse expect to administer?

)

HBV immune globulin

)

HBV vaccine

)

Acylcovir

)

Valacyclovir

)

HBV immune globulin

)

HBV vaccine

)

Acylcovir

)

Valacyclovir

After teaching a pregnant woman with iron deficiency anemia about nutrition,

the nurse determines that the teaching was successful when the woman

identifies which of the following as being good sources of iron in her diet?

(Select all that apply.)

)

Dried fruits

)

Peanut butter

)

Meats

)

Milk

)

White bread

A group of nursing students are preparing a presentation for their class about

measures to prevent toxoplasmosis. Which of the following would the students

be least likely to include? Select all that apply.

)

Washing raw fruits and vegetables before eating them

)

Cooking all meat to an internal temperature of 140 F

)

Wearing gardening gloves when working in the soil

)

Avoiding contact with a cats litter box.

)

Cooking all meat to an internal temperature of 140 F

)

Wearing gardening gloves when working in the soil

)

Avoiding contact with a cats litter box.

A pregnant woman with gestational diabetes comes to the clinic for a fasting

blood glucose level. When reviewing the results, the nurse determines that

which result indicates good glucose control?

)

90 mg/dL

)

100 mg/dL

)

110 mg /dL

)

120 mg/dL

Chapter 21 Nursing Management of Labor and Birth at Risk

After spontaneous rupture of membranes, the nurse notices a prolapsed cord.

The nurse immediately places the woman in which position?

)

Supine

)

Side-lying

)

Sitting

)

Kneechest

)

Supine

)

Side-lying

)

Sitting

)

Kneechest

A primigravida whose labor was initially progressing normally is now

experiencing a decrease in the frequency and intensity of her contractions. The

nurse would assess the woman for which condition?

)

A low-lying placenta

)

Fetopelvic disproportion

)

Contraction ring

)

Uterine bleeding

The nurse would be alert for possible placental abruption during labor when

assessment reveals which of the following?

)

Macrosomia

)

Gestational hypertension

)

Gestational diabetes

)

Low parity

Assessment of a woman in labor who is experiencing hypertonic uterine

dysfunction would reveal contractions that are:

)

Well coordinated

)

Poor in quality

)

Rapidly occurring

)

Erratic

A woman in labor is experiencing hypotonic uterine dysfunction. Assessment

reveals no fetopelvic disproportion. Which group of medications would the

nurse expect to administer?

)

Sedatives

)

Tocolytics

)

Oxytocins

)

Corticosteroids

The fetus of a woman in labor is determined to be in persistent occiput posterior

position. Which of the following would the nurse identify as the priority

intervention?

)

Position changes

)

Pain relief measures

)

Immediate cesarean birth

)

Oxytocin administration

position. Which of the following would the nurse identify as the priority

intervention?

)

Position changes

)

Pain relief measures

)

Immediate cesarean birth

)

Oxytocin administration

A woman gave birth to a newborn via vaginal delivery with the use of a vacuum

extractor. The nurse would be alert for which of the following in the newborn?

)

Asphyxia

)

Clavicular fracture

)

Caput succedaneum

)

Central nervous system injury

A pregnant client undergoing labor induction is receiving an oxytocin infusion.

Which of the following findings would require immediate intervention?

)

Fetal heart rate of 150 beats/minute

)

Contractions every 2 minutes, lasting 45 seconds

)

Uterine resting tone of 14 mm Hg

)

Urine output of 20 mL/hour

A woman with a history of crack cocaine abuse is admitted to the labor and birth

area. While caring for the client, the nurse notes a sudden onset of fetal

bradycardia. Inspection of the abdomen reveals an irregular wall contour. The

client also complains of acute abdominal pain that is continuous. Which of the

following would the nurse suspect?

)

Amniotic fluid embolism

)

Shoulder dystocia

)

Uterine rupture

)

Umbilical cord prolapse

When assessing several women for possible VBAC, which woman would the

nurse identify as being the best candidate?

)

One who has undergone a previous myomectomy

)

One who had a previous cesarean birth via a low transverse incision

)

One who has a history of a contracted pelvis

)

One who has a vertical incision from a previous cesarean birth

A woman is to undergo an amnioinfusion. Which statement would be most

appropriate to include when teaching the woman about this procedure?

)

Youll need to stay in bed while youre having this procedure.

)

Well give you an analgesic to help reduce the pain.

After the infusion, youll be scheduled for a cesarean birth.

A woman is to undergo an amnioinfusion. Which statement would be most

appropriate to include when teaching the woman about this procedure?

)

Youll need to stay in bed while youre having this procedure.

)

Well give you an analgesic to help reduce the pain.

)

After the infusion, youll be scheduled for a cesarean birth.

)

A suction cup is placed on your babys head to help bring it out.

Which finding would indicate to the nurse that a womans cervix is ripe in

preparation for labor induction?

)

Posterior position

)

Firm

)

Closed

)

Shortened

A woman with preterm labor is receiving magnesium sulfate. Which finding

would require the nurse to intervene immediately?

)

Respiratory rate of 16 breaths per minute

)

Diminished deep tendon reflexes

)

Urine output of 45 mL/hour

)

Alert level of consciousness

)

Respiratory rate of 16 breaths per minute

)

Diminished deep tendon reflexes

)

Urine output of 45 mL/hour

)

Alert level of consciousness

A woman who is 42 weeks pregnant comes to the clinic. Which of the following

would be most important?

)

Determining an accurate gestational age

)

Asking her about the occurrence of contractions

)

Checking for spontaneous rupture of membranes

)

Measuring the height of the fundus

After teaching a couple about what to expect with their planned cesarean birth,

which statement indicates the need for additional teaching?

)

Holding a pillow against my incision will help me when I cough.

)

Im going to have to wait a few days before I can start breast-feeding.

)

I guess the nurses will be getting me up and out of bed rather quickly.

)

Ill probably have a tube in my bladder for about 24 hours or so.

The nurse is providing care to several pregnant women who may be scheduled

for labor induction. The nurse identifies the woman with which Bishop score as

having the best chance for a successful induction and vaginal birth?

)

After teaching a group of nursing students about risk factors associated with

dystocia, the instructor determines that the teaching was successful when the

students identify which of the following as increasing the risk? (Select all that

apply.)

)

Pudendal block anesthetic use

)

Multiparity

)

Short maternal stature

)

Maternal age over 35

)

Breech fetal presentation

A nurse is preparing an inservice education program for a group of nurses about

dystocia involving problems with the passenger. Which of the following would

the nurse most likely include as the most common problem?

)

Macrosomia

)

Breech presentation

A nurse is preparing an inservice education program for a group of nurses about

dystocia involving problems with the passenger. Which of the following would

the nurse most likely include as the most common problem?

)

Macrosomia

)

Breech presentation

)

Persistent occiput posterior position

)

Multifetal pregnancy

After teaching a group of nursing students about tocolytic therapy, the instructor

determines that the teaching was successful when they identify which drug as

being used for tocolysis? (Select all that apply.)

)

Nifedipine

)

Terbutaline

)

Dinoprostone

)

Misoprostol

)

Indomethacin

A nurse is assessing a pregnant woman who has come to the clinic. The woman

reports that she feels some heaviness in her thighs since yesterday. The nurse

suspects that the woman may be experiencing preterm labor based on which

additional assessment findings?

)

Dull low backache

)

Malodorous vaginal discharge

)

Dysuria

Constipation

suspects that the woman may be experiencing preterm labor based on which

additional assessment findings?

)

Dull low backache

)

Malodorous vaginal discharge

)

Dysuria

)

Constipation

A nurse is teaching a pregnant woman at risk for preterm labor about what to do

if she experiences signs and symptoms. The nurse determines that the teaching

was successful when the woman states that if she experiences any symptoms,

she will do which of the following?

)

Ill sit down to rest for 30 minutes.

)

Ill try to move my bowels.

)

Ill lie down with my legs raised.

)

Ill drink several glasses of water.

A nurse is describing the risks associated with prolonged pregnancies as part of

an inservice presentation. Which of the following would the nurse be least likely

to incorporate in the discussion as an underlying reason for problems in the

fetus?

)

Aging of the placenta

)

Increased amniotic fluid volume

)

Meconium aspiration

)

Cord compression

)

Increased amniotic fluid volume

)

Meconium aspiration

)

Cord compression

A group of nursing students are reviewing information about methods used for

cervical ripening. The students demonstrate understanding of the information

when they identify which of the following as a mechanical method?

)

Herbal agents

)

Laminaria

)

Membrane stripping

)

Amniotomy

The nurse notifies the obstetrical team immediately because the nurse suspects

that the pregnant woman may be exhibiting signs and symptoms of amniotic

fluid embolism. Which findings would the nurse most likely assess? (Select all

that apply.)

)

Significant difficulty breathing

)

Hypertension

)

Tachycardia

)

Pulmonary edema

)

Bleeding with bruising

A group of nursing students are reviewing information about cesarean birth. The

students demonstrate understanding of the information when they identify

which of the following as an appropriate indication? (Select all that apply..

)

Active genital herpes infection

)

Placenta previa

)

Previous cesarean birth

)

Prolonged labor

)

Fetal distress

A pregnant woman is receiving misoprostol to ripen her cervix and induce

labor. The nurse assesses the woman closely for which of the following?

)

Uterine hyperstimulation

)

Headache

)

Blurred vision

)

Hypotension

Chapter 22 Nursing Management of the Postpartum Woman at Risk

Review of a primiparous womans labor and birth record reveals a prolonged

second stage of labor and extended time in the stirrups. Based on an

interpretation of these findings, the nurse would be especially alert for which of

the following?

)

Retained placental fragments

)

Hypertension

)

Thrombophlebitis

)

Uterine subinvolution

As part of an inservice program, a nurse is describing a transient, self-limiting

mood disorder that affects mothers after childbirth. The nurse correctly identifies

this as postpartum:

)

Depression

)

Psychosis

)

Bipolar disorder

)

Blues

A woman who is 2 weeks postpartum calls the clinic and says, My left breast

hurts. After further assessment on the phone, the nurse suspects the woman has

mastitis. In addition to pain, the nurse would assess for which of the following?

)

An inverted nipple on the affected breast

)

No breast milk in the affected breast

)

An ecchymotic area on the affected breast

)

Hardening of an area in the affected breast

A group of students are reviewing the causes of postpartum hemorrhage. The

students demonstrate understanding of the information when they identify which

of the following as the most common cause?

)

Labor augmentation

)

Uterine atony

)

Cervical or vaginal lacerations

)

Uterine inversion

After presenting a class on measures to prevent postpartum hemorrhage, the

presenter determines that the teaching was successful when the class states

which of the following as an important measure to prevent postpartum

hemorrhage due to retained placental fragments?

)

Administering broad-spectrum antibiotics

)

Inspecting the placenta after delivery for intactness

)

Manually removing the placenta at delivery

which of the following as an important measure to prevent postpartum

hemorrhage due to retained placental fragments?

)

Administering broad-spectrum antibiotics

)

Inspecting the placenta after delivery for intactness

)

Manually removing the placenta at delivery

)

Applying pressure to the umbilical cord to remove the placenta

A multipara client develops thrombophlebitis after delivery. Which of the

following would alert the nurse to the need for immediate intervention?

)

Dyspnea, diaphoresis, hypotension, and chest pain

)

Dyspnea, bradycardia, hypertension, and confusion

)

Weakness, anorexia, change in level of consciousness, and coma

)

Pallor, tachycardia, seizures, and jaundice

A client experienced prolonged labor with prolonged premature rupture of

membranes. The nurse would be alert for which of the following in the mother

and the newborn?

)

Infection

)

Hemorrhage

)

Trauma

)

Hypovolemia

When assessing the postpartum woman, the nurse uses indicators other than

pulse rate and blood pressure for postpartum hemorrhage based on the

knowledge that:

)

These measurements may not change until after the blood loss is large

)

The bodys compensatory mechanisms activate and prevent any changes

)

They relate more to change in condition than to the amount of blood lost

)

Maternal anxiety adversely affects these vital signs

The nurse is assessing a woman with abruption placentae who has just given

birth. The nurse would be alert for which of the following?

)

Severe uterine pain

)

Board-like abdomen

)

Appearance of petechiae

)

Inversion of the uterus

A nurse is assessing a postpartum woman. Which finding would cause the nurse

to be most concerned?

)

Leg pain on ambulation with mild ankle edema

)

Calf pain with dorsiflexion of the foot.

)

Perineal pain with swelling along the episiotomy

Sharp stabbing chest pain with shortness of breath

to be most concerned?

)

Leg pain on ambulation with mild ankle edema

)

Calf pain with dorsiflexion of the foot.

)

Perineal pain with swelling along the episiotomy

)

Sharp stabbing chest pain with shortness of breath

A woman experiencing postpartum hemorrhage is ordered to receive a

uterotonic agent. Which of the following would the nurse least expect to

administer?

)

Oxytocin

)

Methylergonovine

)

Carboprost

)

Terbutaline

Which of the following would be most appropriate when massaging a womans

fundus?

)

Place the hands on the sides of the abdomen to grasp the uterus.

)

Use an up-and-down motion to massage the uterus.

)

Wait until the uterus is firm to express clots.

)

Continue massaging the uterus for at least 5 minutes.

)

Use an up-and-down motion to massage the uterus.

)

Wait until the uterus is firm to express clots.

)

Continue massaging the uterus for at least 5 minutes.

After teaching a woman with a postpartum infection about care after discharge,

which client statement indicates the need for additional teaching?

)

I need to call my doctor if my temperature goes above 100.4 F.

)

When I put on a new pad, Ill start at the back and go forward.

)

If I have chills or my discharge has a strange odor, Ill call my doctor.

)

Ill point the spray of the peribottle so the water flows front to back.

A nurse suspects that a postpartum client is experiencing postpartum psychosis.

Which of the following would most likely lead the nurse to suspect this

condition?

)

Delirium

)

Feelings of anxiety

)

Sadness

)

Insomnia

A postpartum woman is diagnosed with metritis. The nurse interprets this as an

infection involving which of the following? (Select all that apply.)

)

Endometrium

)

Decidua

A postpartum woman is diagnosed with metritis. The nurse interprets this as an

infection involving which of the following? (Select all that apply.)

)

Endometrium

)

Decidua

)

Myometrium

)

Broad ligament

)

Ovaries

)

Fallopian tubes

A group of nursing students are reviewing information about mastitis and its

causes. The students demonstrate understanding of the information when they

identify which of the following as the most common cause?

)

coli

)

aureus

)

Proteus

)

Klebsiella

A home health care nurse is assessing a postpartum woman who was discharged

2 days ago. The woman tells the nurse that she has a low-grade fever and feels

lousy. Which of the following findings would lead the nurse to suspect metritis?

(Select all that apply.)

)

Lower abdominal tenderness

)

Urgency

Flank pain

A home health care nurse is assessing a postpartum woman who was discharged

2 days ago. The woman tells the nurse that she has a low-grade fever and feels

lousy. Which of the following findings would lead the nurse to suspect metritis?

(Select all that apply.)

)

Lower abdominal tenderness

)

Urgency

)

Flank pain

)

Breast tenderness

)

Anorexia

A postpartum client comes to the clinic for her routine 6-week visit. The nurse

assesses the client and suspects that she is experiencing subinvolution based on

which of the following?

)

Nonpalpable fundus

)

Moderate lochia serosa

)

Bruising on arms and legs

)

Fever

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding

and a localized bluish bulging area just under the skin at the perineum. The

woman also is complaining of significant pelvic pain and is experiencing

problems with voiding. The nurse suspects which of the following?

)

Hematoma

)

Laceration

)

Bladder distention

Uterine atony

woman also is complaining of significant pelvic pain and is experiencing

problems with voiding. The nurse suspects which of the following?

)

Hematoma

)

Laceration

)

Bladder distention

)

Uterine atony

A postpartum woman is ordered to receive oxytocin to stimulate the uterus to

contract. Which of the following would be most important for the nurse to do?

)

Administer the drug as an IV bolus injection.

)

Give as a vaginal or rectal suppository.

)

Piggyback the IV infusion into a primary line.

)

Withhold the drug if the woman is hypertensive.

Assessment of a postpartum woman experiencing postpartum hemorrhage

reveals mild shock. Which of the following would the nurse expect to assess?

(Select all that apply.)

)

Diaphoresis

)

Tachycardia

)

Oliguria

)

Cool extremities

)

Confusion

)

Tachycardia

)

Oliguria

)

Cool extremities

)

Confusion

A group of students are reviewing risk factors associated with postpartum

hemorrhage. The students demonstrate understanding of the information when

they identify which of the following as associated with uterine tone? (Select all

that apply.)

)

Rapid labor

)

Retained blood clots

)

Hydramnios

)

Operative birth

)

Fetal malpostion

A nurse is massaging a postpartum clients fundus and places the nondominant

hand on the area above the symphysis pubis based on the understanding that this

action:

)

Determines that the procedure is effective

)

Helps support the lower uterine segment

)

Aids in expressing accumulated clots

)

Prevents uterine muscle fatigue

)

Helps support the lower uterine segment

)

Aids in expressing accumulated clots

)

Prevents uterine muscle fatigue

A nurse is developing a plan of care for a woman who is at risk for

thromboembolism. Which of the following would the nurse include as the most

cost-effective method for prevention?

)

Prophylactic heparin administration

)

Compression stocking

)

Early ambulation

)

Warm compresses

A postpartum woman who developed deep vein thrombosis is being discharged

on anticoagulant therapy. After teaching the woman about this treatment, the

nurse determines that additional teaching is needed when the woman states

which of the following?

)

I will use a soft toothbrush to brush my teeth.

)

I can take ibuprofen if I have any pain.

)

I need to avoid drinking any alcohol.

)

I will call my health care provider if my stools are black and tarry.

The nurse is developing a discharge teaching plan for a postpartum woman who

has developed a postpartum infection. Which of the following would the nurse

most likely include in this teaching plan? (Select all that apply.)

)

Taking the prescribed antibiotic until it is finished

)

Checking temperature once a week

)

Washing hands before and after perineal care

)

Handling perineal pads by the edges

)

Directing peribottle to flow from back to front

A nurse is assessing a postpartum client who is at home. Which statement by the

client would lead the nurse to suspect that the client may be developing

postpartum depression?

)

I just feel so overwhelmed and tired.

)

Im feeling so guilty and worthless lately.

)

Its strange, one minute Im happy, the next Im sad.

)

I keep hearing voices telling me to take my baby to the river.

Chapter 23 Nursing Care of the Newborn with Special Needs

The nurse is teaching a group of students about the differences between a fullterm

newborn and a preterm newborn. The nurse determines that the teaching is

effective when the students state that the preterm newborn has:

)

Fewer visible blood vessels through the skin

)

More subcutaneous fat in the neck and abdomen

)

Well-developed flexor muscles in the extremities

)

Greater surface area in proportion to weight

When assessing a postterm newborn, which of the following would the nurse

correlate with this gestational age variation?

)

Moist, supple, plum skin appearance

)

Abundant lanugo and vernix

)

Thin umbilical cord

)

Absence of sole creases

The parents of a preterm newborn being cared for in the neonatal intensive care

unit (NICU. are coming to visit for the first time. The newborn is receiving

mechanical ventilation and intravenous fluids and medications and is being

monitored electronically by various devices. Which action by the nurse would be

most appropriate?

)

Suggest that the parents stay for just a few minutes to reduce their anxiety.

)

Reassure them that their newborn is progressing well.

)

Encourage the parents to touch their preterm newborn.

)

Discuss the care they will be giving the newborn upon discharge.

When performing newborn resuscitation, which action would the nurse do

first?

)

Intubate with an appropriate-sized endotracheal tube.

)

Give chest compressions at a rate of 80 times per minute.

)

Administer epinephrine intravenously.

)

Suction the mouth and then the nose.

The nurse frequently assesses the respiratory status of a preterm newborn based

on the understanding that the newborn is at increased risk for respiratory distress

syndrome because of which of the following?

)

Inability to clear fluids

)

Immature respiratory control center

)

Deficiency of surfactant

on the understanding that the newborn is at increased risk for respiratory distress

syndrome because of which of the following?

)

Inability to clear fluids

)

Immature respiratory control center

)

Deficiency of surfactant

)

Smaller respiratory passages

The nurse prepares to assess a newborn who is considered to be large for

gestational age (LGA). Which of the following would the nurse correlate with

this gestational age variation?

)

Strong, brisk motor skills

)

Difficulty in arousing to a quiet alert state

)

Birth weight of 7 lb 14 oz

)

Wasted appearance of extremities

An LGA newborn has a blood glucose level of 30 mg/dL and is exhibiting

symptoms of hypoglycemia. Which of the following would the nurse do next?

)

Administer intravenous glucose immediately.

)

Feed the newborn 2 ounces of formula.

)

Initiate blow-by oxygen therapy.

)

Place the newborn under a radiant warmer.

A group of pregnant women are discussing high-risk newborn conditions as part

of a prenatal class. When describing the complications that can occur in these

newborns to the group, which would the nurse include as being at lowest risk?

)

Small-for-gestational-age (SGA. newborns

)

Large-for-gestational-age (LGA. newborns

)

Appropriate-for-gestational-age (AGA. newborns

)

Low-birth-weight newborns

While caring for a preterm newborn receiving oxygen therapy, the nurse

monitors the oxygen therapy duration closely based on the understanding that

the newborn is at risk for which of the following?

)

Retinopathy of prematurity

)

Metabolic acidosis

)

Infection

)

Cold stress

When planning the care for an SGA newborn, which action would the nurse

determine as a priority?

)

Preventing hypoglycemia with early feedings

)

Observing for respiratory distress syndrome

)

Promoting bonding between the parents and the newborn

determine as a priority?

)

Preventing hypoglycemia with early feedings

)

Observing for respiratory distress syndrome

)

Promoting bonding between the parents and the newborn

)

Monitoring vital signs every 2 hours

A woman gives birth to a newborn at 36 weeks gestation. She tells the nurse, Im

so glad that my baby isnt premature. Which response by the nurse would be

most appropriate?

)

You are lucky to have given birth to a term newborn.

)

We still need to monitor him closely for problems.

)

How do you feel about delivering your baby at 36 weeks?

)

Your baby is premature and needs monitoring in the NICU.

Which of the following would be most appropriate for the nurse to do when

assisting parents who have experienced the loss of their preterm newborn?

)

Avoid using the terms death or dying.

)

Provide opportunities for them to hold the newborn.

)

Refrain from initiating conversations with the parents.

)

Quickly refocus the parents to a more pleasant topic.

)

Provide opportunities for them to hold the newborn.

)

Refrain from initiating conversations with the parents.

)

Quickly refocus the parents to a more pleasant topic.

Which of the following, if noted in the maternal history, would the nurse

identify as possibly contributing to the birth of an LGA newborn?

)

Drug abuse

)

Diabetes

)

Preeclampsia

)

Infection

Which of the following would alert the nurse to suspect that a preterm newborn

is in pain?

)

Bradycardia

)

Oxygen saturation level of 94%

)

Decreased muscle tone

)

Sudden high-pitched cry

When describing newborns with birth-weight variations to a group of nursing

students, the instructor identifies which variation if the newborn weighs 5.2 lb at

any gestational age?

)

Small for gestational age

)

Low birth weight

When describing newborns with birth-weight variations to a group of nursing

students, the instructor identifies which variation if the newborn weighs 5.2 lb at

any gestational age?

)

Small for gestational age

)

Low birth weight

)

Very low birth weight

)

Extremely low birth weight

A nurse is assessing a newborn who has been classified as small for gestational

age. Which of the following would the nurse expect to find? (Select all that

apply.)

)

Wasted extremity appearance

)

Increased amount of breast tissue

)

Sunken abdomen

)

Adequate muscle tone over buttocks

)

Narrow skull sutures

The nurse is reviewing the medical record of a newborn born 2 hours ago. The

nurse notes that the newborn was delivered at 35 weeks gestation. The nurse

would classify this newborn as which of the following?

)

Preterm

)

Late preterm

)

Full term

)

Postterm

nurse notes that the newborn was delivered at 35 weeks gestation. The nurse

would classify this newborn as which of the following?

)

Preterm

)

Late preterm

)

Full term

)

Postterm

A nursing instructor is describing common problems associated with preterm

birth. When describing the preterm newborns risk for perinatal asphyxia, the

instructor includes which of the following as contributing to the newborns risk?

(Select all that apply.)

)

Surfactant deficiency

)

Placental deprivation

)

Immaturity of the respiratory control centers

)

Decreased amounts of brown fat

)

Depleted glycogen stores

After determining that a newborn is in need of resuscitation, which of the

following would the nurse do first?

)

Dry the newborn thoroughly

)

Suction the airway

)

Administer ventilations

)

Give volume expanders

)

Dry the newborn thoroughly

)

Suction the airway

)

Administer ventilations

)

Give volume expanders

A nurse is developing a plan of care for a preterm infant experiencing

respiratory distress. Which of the following would the nurse be least likely to

include in this plan?

)

Stimulate the infant with frequent handling.

)

Keep the newborn in a warmed isolette.

)

Administer oxygen using a oxygen hood.

)

Give gavage or continous tube feedings.

A nurse suspects that a preterm newborn is having problems with thermal

regulation. Which of the following would support the nurses suspicion? (Select

all that apply.)

)

Shallow, slow respirations

)

Cyanotic hands and feet

)

Irritability

)

Hypertonicity

)

Feeble cry

)

Irritability

)

Hypertonicity

)

Feeble cry

The nurse is assessing a preterm newborns fluid and hydration status. Which of

the following would alert the nurse to possible overhydration?

)

Decreased urine output

)

Tachypnea

)

Bulging fontanels

)

Elevated temperature

The nurse is assessing a preterm newborn who is in the neonatal intensive care

unit (NICU. for signs and symptoms of overstimulation. Which of the following

would the nurse be least likely to assess?

)

Increased respirations

)

Flaying hands

)

Periods of apnea

)

Decreased heart rate

A group of nursing students are reviewing the literature in preparation for a

class presentation on newborn pain prevention and management. Which of the

following would the students be most likely to find about this topic?

)

Newborn pain is frequently recognized and treated

)

Newborns rarely experience pain with procedures

A group of nursing students are reviewing the literature in preparation for a

class presentation on newborn pain prevention and management. Which of the

following would the students be most likely to find about this topic?

)

Newborn pain is frequently recognized and treated

)

Newborns rarely experience pain with procedures

)

Pain is frequently mistaken for irritability or agitation

)

Newborns may be less sensitive to pain than adult.

A nurse is developing a plan of care for a preterm newborn to address the

nursing diagnosis of risk for delayed development. Which of the following

would the nurse include? (Select all that apply.)

)

Clustering care to promote rest

)

Positioning newborn in extension

)

Using kangaroo care

)

Loosely covering the newborn with blankets

)

Providing nonnutritive sucking

A nurse is assisting the anxious parents of a preterm newborn to cope with the

situation. Which statement by the nurse would be least appropriate?

)

Ill be here to help you all along the way.

)

What has helped you to deal with stressful situations in the past?

)

Let me tell you about what you will see when you visit your baby.

)

Forget about whats happened in the past and focus on the now.

situation. Which statement by the nurse would be least appropriate?

)

Ill be here to help you all along the way.

)

What has helped you to deal with stressful situations in the past?

)

Let me tell you about what you will see when you visit your baby.

)

Forget about whats happened in the past and focus on the now.

Chapter 24 Nursing Management of the Newborn at Risk: Acquired & Congenital Newborn Conditions

A newborn with severe meconium aspiration syndrome (MAS. is not responding

to conventional treatment. Which of the following would the nurse anticipate as

possibly necessary for this newborn?

)

Extracorporeal membrane oxygenation (ECMO)

)

Respiratory support with a ventilator

)

Insertion of a laryngoscope for deep suctioning

)

Replacement of an endotracheal tube via x-ray

Which of the following would the nurse expect to assess in a newborn who

develops sepsis?

)

Increased urinary output

)

Interest in feeding

Which of the following would the nurse expect to assess in a newborn who

develops sepsis?

)

Increased urinary output

)

Interest in feeding

)

Hypothermia

)

Wakefulness

Which of the following would the nurse include in the plan of care for a

newborn receiving phototherapy?

)

Keeping the newborn in the supine position

)

Covering the newborns eyes while under the bililights

)

Ensuring that the newborn is covered or clothed

)

Reducing the amount of fluid intake to 8 ounces daily

A newborn has been diagnosed with a Group B streptococcal infection shortly

after birth. The nurse understands that the newborn most likely acquired this

infection from which of the following?

)

Improper handwashing

)

Contaminated formula

)

Nonsterile catheter insertion

)

Mothers birth canal

)

Contaminated formula

)

Nonsterile catheter insertion

)

Mothers birth canal

Which action would be most appropriate for the nurse to take when a newborn

has an unexpected anomaly at birth?

)

Show the newborn to the parents as soon as possible while explaining the defect.

)

Remove the newborn from the birthing area immediately.

)

Inform the parents that there is nothing wrong at the moment.

)

Tell the parents that the newborn must go to the nursery immediately.

The nurse prepares to administer a gavage feeding for a newborn with transient

tachypnea based on the understanding that this type of feeding is necessary for

which reason?

)

Lactase enzymatic activity is not adequate.

)

Oxygen demands need to be reduced.

)

Renal solute lead must be considered.

)

Hyperbilirubinemia is likely to develop.

Which of the following would the nurse include when teaching a new mother

about the difference between pathologic and physiologic jaundice?

)

Physiologic jaundice results in kernicterus.

)

Pathologic jaundice appears within 24 hours after birth.

)

Both are treated with exchange transfusions of maternal O- blood.

Which of the following would the nurse include when teaching a new mother

about the difference between pathologic and physiologic jaundice?

)

Physiologic jaundice results in kernicterus.

)

Pathologic jaundice appears within 24 hours after birth.

)

Both are treated with exchange transfusions of maternal O- blood.

)

Physiologic jaundice requires transfer to the NICU.

When planning the care of a newborn addicted to cocaine who is experiencing

withdrawal, which of the following would be least appropriate to include?

)

Wrapping the newborn snugly in a blanket

)

Waking the newborn every hour

)

Checking the newborns fontanels

)

Offering a pacifier

A newborn is suspected of having fetal alcohol syndrome. Which of the

following would the nurse expect to assess?

)

Bradypnea

)

Hydrocephaly

)

Flattened maxilla

)

Hypoactivity

)

Hydrocephaly

)

Flattened maxilla

)

Hypoactivity

After teaching the parents of a newborn with periventricular hemorrhage about

the disorder and treatment, which statement by the parents indicates that the

teaching was successful?

)

Well make sure to cover both of his eyes to protect them.

)

Our newborn could develop a learning disability later on.

)

Once the bleeding ceases, there wont be any more worries.

)

We need to get family members to donate blood for transfusion.

A newborn has an Apgar score of 6 at 5 minutes. Which of the following is the

priority?

)

Initiating IV fluid therapy

)

Beginning resuscitative measures

)

Promoting kangaroo care

)

Obtaining a blood culture

While reviewing a newborns medical record, the nurse notes that the chest x-ray

shows a ground glass pattern. The nurse interprets this as indicative of:

)

Respiratory distress syndrome

)

Transient tachypnea of the newborn

While reviewing a newborns medical record, the nurse notes that the chest x-ray

shows a ground glass pattern. The nurse interprets this as indicative of:

)

Respiratory distress syndrome

)

Transient tachypnea of the newborn

)

Asphyxia

)

Persistent pulmonary hypertension

A newborn is suspected of developing persistent pulmonary hypertension. The

nurse would expect to prepare the newborn for which of the following to

confirm the suspicion?

)

Chest x-ray

)

Blood cultures

)

Echocardiogram

)

Stool for occult blood

Which of the following would alert the nurse to suspect that a newborn has

developed NEC?

)

Irritability

)

Sunken abdomen

)

Clay-colored stools

)

Bilious vomiting

)

Irritability

)

Sunken abdomen

)

Clay-colored stools

)

Bilious vomiting

Which of the following would not be considered a risk factor for

bronchopulmonary dysplasia (chronic lung disease)?

)

Preterm birth (less than 32 weeks)

)

Female gender

)

White race

)

Sepsis

A group of nursing students are reviewing the different types of congenital heart

disease in infants. The students demonstrate a need for additional review when

they identify which of the following as an example of increased pulmonary

blood flow (left-to-right shunting)?

)

Atrial septal defect

)

Tetralogy of Fallot

)

Ventricular septal defect

)

Patent ductus arteriosus

After teaching the parents of a newborn with retinopathy of prematurity (ROP.

about the disorder and treatment, which statement by the parents indicates that

the teaching was successful?

)

Can we schedule follow-up eye examinations with the pediatric ophthalmologist

now?

)

We can fix the problem with surgery.

)

Well make sure to administer eye drops each day for the next few weeks.

)

Im sure the baby will grow out of it.

The nurse is assessing the newborn of a mother who had gestational diabetes.

Which of the following would the nurse expect to find? (Select all that apply.)

)

Pale skin color

)

Buffalo hump

)

Distended upper abdomen

)

Excessive subcutaneous fat

)

Long slender neck

The nurse is assessing a newborn who is large for gestational age. The newborn

was born breech. The nurse suspects that the newborn may have experienced

trauma to the upper brachial plexus based on which assessment findings?

)

Absent grasp reflex

)

Hand weakness

Absent Moro reflex

The nurse is assessing a newborn who is large for gestational age. The newborn

was born breech. The nurse suspects that the newborn may have experienced

trauma to the upper brachial plexus based on which assessment findings?

)

Absent grasp reflex

)

Hand weakness

)

Absent Moro reflex

)

Facial asymmetry

The nurse is assessing a newborn and suspects that the newborn was exposed to

drugs in utero because the newborn is exhibiting signs of neonatal abstinence

syndrome. Which of the following would the nurse expect to assess? (Select all

that apply.)

)

Tremors

)

Diminished sucking

)

Regurgitation

)

Shrill, high-pitched cry

)

Hypothermia

)

Frequent sneezing

A nurse is developing a plan of care for a newborn with omphalocele. Which of

the following would the nurse include?

)

Placing the newborn into a sterile drawstring bowel bag

)

Using clean technique for dressing changes

Preparing the newborn for incision and drainage

A nurse is developing a plan of care for a newborn with omphalocele. Which of

the following would the nurse include?

)

Placing the newborn into a sterile drawstring bowel bag

)

Using clean technique for dressing changes

)

Preparing the newborn for incision and drainage

)

Instituting gavage feedings

A nurse is explaining to the parents of a child with bladder exstrophy about the

care their infant requires. Which of the following would the nurse include in the

explanation? (Select all that apply.)

)

Covering the area with a sterile, clear, nonadherent dressing

)

Irrigating the surface with sterile saline twice a day

)

Monitoring drainage through the suprapubic catheter

)

Administering prescribed antibiotic therapy

)

Preparing for surgical intervention in about 2 weeks

A nursing student is preparing a presentation for the class on clubfoot. The

student determines that the presentation was successful when the class states

which of the following?

)

Clubfoot is a common genetic disorder.

)

The condition affects girls more often than boys.

)

The exact cause of clubfoot is not known.

)

The intrinsic form can be manually reduced.

student determines that the presentation was successful when the class states

which of the following?

)

Clubfoot is a common genetic disorder.

)

The condition affects girls more often than boys.

)

The exact cause of clubfoot is not known.

)

The intrinsic form can be manually reduced.

Assessment of newborn reveals a large protruding tongue, slow reflexes,

distended abdomen, poor feeding, hoarse cry, goiter and dry skin. Which of the

following would the nurse suspect?

)

Phenylketonuria

)

Galactosemia

)

Congenital hypothyroidism

)

Maple syrup urine disease

A group of students are reviewing information about the effects of substances

on the newborn. The students demonstrate understanding of the information

when they identify which drug as not being associated with teratogenic effects

on the fetus?

)

Alcohol

)

Nicotine

)

Marijuana

)

Cocaine

)

Nicotine

)

Marijuana

)

Cocaine

A nurse is teaching the mother of a newborn diagnosed with galactosemia about

dietary restrictions. The nurse determines that the mother has understood the

teaching when she identifies which of the following as needing to be restricted?

)

Phenylalanine

)

Protein

)

Lactose

)

Iodine

A newborn was diagnosed with a congenital heart defect and will undergo

surgery at a later time. The nurse is teaching the parents about signs and

symptoms that need to be reported. The nurse determines that the parents have

understood the instructions when they state that they will report which of the

following? (Select all that apply.)

)

Weight loss

)

Pale skin

)

Fever

)

Absence of edema

)

Increased respiratory rate

)

Increased respiratory rate

When developing the plan of care for a newborn with an acquired condition,

which of the following would the nurse include to promote participation by the

parents?

)

Use verbal instructions primarily for explanations

)

Assist with decision making process

)

Provide personal views about their decisions

)

Encourage them to refrain from showing emotions

A nurse is assisting in the resuscitation of a newborn. The nurse would expect to

stop resuscitation efforts when the newborn has no heartbeat and respiratory

effort after which time frame?

)

5 minutes

)

10 minutes

)

15 minutes

)

20 minutes

A newborn is diagnosed with meconium aspiration syndrome. When assessing

this newborn, which of the following would the nurse expect to find? (Select all

that apply.)

)

Pigeon chest

)

Prolonged tachypnea

)

Intercostal retractions

this newborn, which of the following would the nurse expect to find? (Select all

that apply.)

)

Pigeon chest

)

Prolonged tachypnea

)

Intercostal retractions

)

High blood pH level

)

Coarse crackles on auscultation

Chapter 25 Growth and Development of the Newborn and Infant

A mother calls the pediatricians office because her infant is colicky. The helpful measure the

nurse would suggest to the parent is:

Sing songs to the infant in a soft voice.

Place the infant in a well-lit room.

Walk around and massage the infants back.

Rock the fussy infant slowly and gently.

Place the infant in a well-lit room.

Walk around and massage the infants back.

Rock the fussy infant slowly and gently.

The nurse is aware that the age at which the posterior fontanelle closes is:

2 to 3 months

3 to 6 months

6 to 9 months

9 to 12 months

The nurse knows that an infants birthweight should be tripled by:

9 months

1 year

18 months

2 years

The nurse is aware that the age at which an infant is able to sit steadily alone is:

4 months

5 months

8 months

15 months

4 months

5 months

8 months

15 months

The infant should be able to walk independently by the age of:

8-10 months

12-15 months

15-18 months

18-21 months

The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin

drinking from a cup? The nurse would reply:

5 months

9 months

1 year

2 years

The nurse would expect a 4-month-old to be able to:

Hold a cup

Stand with assistance

Lift head and shoulders

Sit with back straight

The abnormal finding in an evaluation of growth and development for a 6-month-old infant

would be:

Weight gain of 4-7 ounces per week

Length increase of 1 inch in 2 months

Head lag present

Can sit alone for a few seconds

Weight gain of 4-7 ounces per week

Length increase of 1 inch in 2 months

Head lag present

Can sit alone for a few seconds

A parent brings a 6-month-old infant to the pediatric clinic for her well-child examination. Her

birthweight was 8 pounds, 2 ounces. The nurse weighing the infant today would expect her

weight to be at least:

12 pounds

16 pounds

20 pounds

24 pounds

The nurse would advise a parent when introducing solid foods to:

Begin with one tablespoon of the food.

Mix foods together.

Eliminate a refused food from the diet.

Introduce each new food 4 to 7 days apart.

When talking with a parent about tooth eruption, the nurse explains that the first deciduous

teeth to erupt are the:

Lower central incisors

Upper central incisors

Lower lateral incisors

Upper lateral incisors

When assessing development in a 9-month-old infant, the nurse would expect to observe the

infant:

Sitting if supported

Grasping objects with the palm

Imitating sounds such as da-da

Beginning to use a spoon rather sloppily

Grasping objects with the palm

Imitating sounds such as da-da

Beginning to use a spoon rather sloppily

The statement made by a parent that indicates correct understanding of infant feeding is:

Ive been mixing rice cereal and formula in the babys bottle.

I switched the baby to low-fat milk at 9 months.

The baby really likes little pieces of chocolate.

I give the baby any new foods before he takes his bottle.

The nurse would advise a mother who is concerned because her 10-month-old is lethargic, to:

Keep the babys room well-lit.

Rub the babys soles vigorously.

Offer the baby a pacifier.

Handle the infant slowly and gently.

The nurse discusses safety-proofing the home with the mother of a 9-month-old. The

statement made by the mother that indicates an unsafe behavior is:

I put covers on all of the electrical outlets.

In the car, she rides in a front-facing car seat.

There are locks on all of the cabinets in the house.

I have a gate at the top and bottom of the stairs.

The nurse observes a 10-month-old infant using her index finger and thumb to pick up

Cheerios. This behavior is evidence that the infant has developed the:

Pincer grasp

Grasp reflex

Prehension ability

Parachute reflex

A parent is concerned because her infant has a diaper rash. The nurse would advise the parent

to:

Use commercial diaper wipes to clean the area.

Apply a protective ointment on the area.

Change the babys diaper less frequently.

Keep the diaper area covered all of the time.

The mother of an infant born prematurely tells the nurse, The baby is irritable. He cries

during diaper changes and feedings. Can you make some suggestions about what I should do to

soothe him? The most appropriate recommendation to help this parent would be:

Play the radio or TV while you feed the baby.

Put the baby in a room with sunlight.

Cover the baby snugly when you hold him.

Change the babys position quickly.

The most appropriate activity to recommend to parents to promote sensorimotor stimulation

for a 1-year-old would be:

a.Ride a

tricycle.

Spend time in an infant swing.

Play with push-pull toys.

Ride a tricycle.

Spend time in an infant swing.

Play with push-pull toys.

Read large picture books.

The statement that indicates the mother of an 8-month-old understands infant sleep patterns

is:

I put the baby in my bed until she falls asleep, then I put her in her crib.

I let the baby skip an afternoon nap so she will fall asleep earlier.

I put the pacifier in the crib so she can find it when she wakes up.

I rock the baby back to sleep if she wakes up at night.

MULTIPLE RESPONSE

The nurse is aware that the 7-month-old can signal feeding readiness by:

Select all that apply.

Pulling spoon toward mouth

Biting at spoon with upper and lower incisors

Pointing to food bowl

Bouncing up and down with excitement at sight of food

Manipulating finger foods

Chapter 26 Growth and Development of the Toddler

Which of these behaviors reported by a parent of an 18-month-old toddler would the nurse

report to the pediatrician as a cause for concern?

The child has temper tantrums.

The child feeds himself sloppily.

The child walks by holding onto furniture.

The child speaks in short sentences.

The nurse assessing growth and development of a 2-year-old child would expect to find:

That the child jumps with both feet

That 20 deciduous teeth have erupted

That the child can hop on one foot

A vocabulary of 900 words

That the child jumps with both feet

That 20 deciduous teeth have erupted

That the child can hop on one foot

A vocabulary of 900 words

A parent remarks, My 18-month-old daughter carries her blanket around everywhere. Is this

normal? The nurse who has an understanding of toddler development might explain that:

She carries her blanket because she is ritualistic.

Carrying her favorite blanket is self-consoling behavior.

This behavior can be discouraged by offering new toys to the child.

This could be indicative of emotional distress.

The nurse observed three toddlers playing side by side with dolls. Closer observation revealed

that the children were not interacting with one another. This type of play would be characterized

as:

Solitary

Parallel

Associative

Cooperative

The nurse planning anticipatory guidance for parents of a toddler would include which of the

following instructions?

Adhere to a rigid schedule because the toddler is ritualistic.

Limit setting should include praise.

Shoes should fit snugly at the toe and arch.

Dress the toddler in pants with a zipper so he or she can learn to zip and unzip

clothes.

The best advice the nurse can offer a parent who is concerned because her 2-year-old is very

active and does not eat much is:

Insist that the child eat one food on the plate.

Help the child to wind down with a quiet activity before mealtime.

Maintain a consistent eating schedule for the family.

Serve the meal with a variety of interesting plates, cups, and utensils.

Help the child to wind down with a quiet activity before mealtime.

Maintain a consistent eating schedule for the family.

Serve the meal with a variety of interesting plates, cups, and utensils.

How would the nurse advise a parent who states, I never know how much food to feed my

child?

Serving sizes should not exceed 1 teaspoon of each type of food.

Food quantities must be carefully measured to avoid overfeeding.

Use 1 tablespoon of each food for each year of age as a guideline.

A toddler should eat three balanced meals. Snacks are not necessary.

The nurse discussing toilet training with parents would identify which of the following as an

indicator of readiness? The child is:

Willing to sit on the potty for 15 to 20 minutes

Dry in the daytime for 4-hour periods

Able to communicate that he or she is wet

Curious about bathroom activities

The nurse selects the most appropriate toy for a normal 2-year-old child, which is:

A bicycle with training wheels

A dump truck

Wind-up toys

Legos

To encourage a toddler to practice independence, the nurse would recommend that the childs

mother:

Offer a variety of items to choose from to stimulate his mind.

Allow the child to determine his own daily routine.

Offer him a choice between two items.

Set the routine herself, but discuss with her toddler how he or she would have

done it differently.

On a home visit, the nurse notes each of the following. The observation that requires teaching

intervention to protect the 15-month-old child who lives there is:

The fireplace has a screen.

The dining room table has a tablecloth on it.

There are paintings on the wall.

The kitchen floor is clean but not shiny.

The nurse considers the appropriate snack for a 2-year-old child would be:

Hot dog sections

Grapes

Popcorn

Applesauce

The nurse assessing vital signs on a 2-year-old would be concerned about the finding of:

Temperature 98.8 F

Pulse 100 beats/min

Respirations 36 breaths/min

Blood pressure 90/60 mm Hg

When assessing language development in a 2-year-old, an expected finding would be:

A 900-word vocabulary

Use of two-word sentences

Use of pronouns and prepositions

100% of speech is understandable

The nurse has explained the use of time-outs to the parent of a 3-year-old. The nurse

determines the parent understands the information when she states an appropriate period for a

time-out is:

3 minutes

6 minutes

10 minutes

15 minutes

The parent of a toddler tells the nurse, My daughters appetite has decreased. Thank goodness

she loves to drink milk. The most appropriate response for the nurse to make is:

Has your daughter been sick recently?

How much milk does she drink in a day?

Has she become a fussy eater, too?

Have you tried offering her finger foods?

The nurse suggests that bladder training should start when the toddler can stay dry for _____

hours.

Chapter 27 Growth and Development of the Preschooler

MULTIPLE CHOICE

Which of the following statements best describes the 3-year-old child?

Boisterous, tattles on others

Aggressive, shows off

Helpful, wants to assist with chores

Talkative, inquisitive about the environment

The parents of a 4-year-old boy are concerned because they have noticed him frequently

touching his penis. The nurse would base a response on the knowledge that:

This behavior indicates a normal curiosity about sexuality.

Masturbation suggests the boy has an excessive fear of castration.

It is usually a result of discomfort from a penile rash or irritation.

The behavior is abnormal and the child should be referred for counseling.

A preschool-age child is asked, Why do trees have leaves? Which of the following responses

would be an example of animism?

So I can have shade over my sandbox.

Because God made them that way.

To hide behind when they are scared.

For the squirrels to play in.

The tasks that would be appropriate to expect of a 5-year-old would be:

Setting the table with paper plates

Washing the dirty knives

Carrying glasses from the table to the sink

Scrubbing out the sink with cleanser

A 3-year-old child, while playing with her favorite toy in the playroom of the pediatric unit, is

approached by another child who also wants to play with the same toy. The nurse anticipates that

the 3-year-old will:

Play well with the other child

Give the toy up and then not play any more

Become angry and a physical response might ensue

Ignore the toy and go on to something else

A parent is concerned about her childrens reaction should their grandmother die. In planning a

response, the nurse is guided by the understanding that:

Children are unlikely to notice their grandmothers absence if no one reminds

them.

Young children often understand that other people die, but do not equate it with

themselves.

The childrens response will depend entirely on whether they have been

acquainted with death before this.

Children can understand the concept of a higher being much like adults can.

The intervention that is most effective in dealing with occasional aggression in a 4-year-old

child is:

Have the child take a time-out in the corner for 4 minutes.

Spank the child at the time of the incident.

Take away television privileges for the day.

Send the child to his room for 30 minutes.

Have the child take a time-out in the corner for 4 minutes.

Spank the child at the time of the incident.

Take away television privileges for the day.

Send the child to his room for 30 minutes.

A parent is concerned about how to make his preschool-age child stop sucking his thumb and

asks the nurse for suggestions. The nurses most helpful response would be:

Most children will stop thumb-sucking naturally by school age.

Over-the-counter treatments that give a bad taste can be placed on the thumb to

discourage the practice.

Consistently touching the childs fingers whenever he sucks his thumb is most

effective.

Thumb-sucking is detrimental to the eruption of the childs teeth and must be

stopped as soon as possible.

The nurse characterizes the play of 5-year-old children as:

Rough and tumble play

Well-organized games

Following rules

Prefer inside activities

When discussing preschoolers sexual curiosity with the parent, the nurse determines that the

parent understands the information when she states she would:

Make up funny words for body parts.

Distract my child with a toy if she asks about sex.

Answer her questions when she asks.

Tell her to ask me again when she is 6 years old.

In planning care for a moderately retarded child, the type of play most appropriate is:

Play should exercise leg and arm muscles.

Play should be educationally oriented to make up for lost time.

c.Play should be adjusted to her mental age rather than her chronological age.

Play is not a necessary component of the care of a mentally retarded child.

Play should exercise leg and arm muscles.

Play should be educationally oriented to make up for lost time.

Play should be adjusted to her mental age rather than her chronological age.

Play is not a necessary component of the care of a mentally retarded child.

The nurses best advice to a parent about a preschoolers imaginary friend would be that:

Imaginary friends is a sign that the child has a low self-esteem.

It is common for preschoolers to have imaginary friends.

The preschooler invents an imaginary friend when he feels overwhelmed.

The best approach to dealing with an imaginary friend is to ignore them.

The nurse suggests measures that might be helpful for the child with enuresis, such as:

Apply an electric pad that gently shocks the child.

Wake the child several times during the night to urinate.

Decrease fluid intake after the evening meal.

Increase dietary fiber intake.

The nurse suggests that the most appropriate toy choice for a 3-year-old would be:

A board game

A small pet, such as a goldfish

A large construction set

Push-pull toys

The parent of a 3-year-old child tells the nurse, My daughter points whenever she wants me

to get something for her but she understands me when I ask her to do something. Based on the

parents comment, the nurse recognizes that:

The childs language development is age-appropriate.

The child may have expressive language delay.

The child has a receptive language delay.

The child should have her hearing tested.

The child has a receptive language delay.

The child should have her hearing tested.

The parent of a 4-year-old child tells the nurse, Bedtime is difficult. I cant get my child to

bed at night. The nurse and the childs mother discuss options and decide that the best choice

would be to:

Allow the child to put himself to bed when he is tired.

Let the child read in his room until he falls asleep.

Establish a bedtime routine and use it consistently.

Tire him out with physical activity before bedtime.

The nurse understands that a fear unique to the preschool period is:

Fear of water

Fear of animals

Fear of bodily harm

Fear of death

A 4-year-old child tells the nurse that he will not eat peas because they are green. This is an

example of:

Egocentrism

Artificialism

Animism

Centering

A 4-year-old child insists that he has more money with a nickel than his father has with a

dime. The nurse is aware that this perception is described in Piagets theory as:

Egocentrism

Artificialism

Animism

Centering

Animism

Centering

Chapter 28 Growth and Development of the School-Age Child

The nurse is aware that, in general, the school-age child will:

Grow 3 to 6 inches/year

Gain 5 to 7 pounds/year

Increase head circumference by 1 inch/year

Reach a visual acuity of 20/20 by 9 years of age

The nurse, planning to teach a class on nutrition to fourth-grade students, would keep in mind

that school-age children:

Can concentrate on only one aspect of a situation

Can think abstractly

Are egocentric in their thinking

Think logically and concretely

The nurse explains that the preferred social interaction for the school-age child is based on

relationships that are:

Heterosexual interest groups

Association with one best friend

Organized groups like Boy Scouts

Same-sex peer groups

Organized groups like Boy Scouts

Same-sex peer groups

The nurse advises the parents of a 10-year-old boy that, according to Eriksons theory, the most

developmentally supportive experience for him would be:

Constant variety of activities

Successful performance in Little League

Feeling healthy and strong

Having a girl friend

The parents of an 8-year-old tell the nurse the child wakes the household crying out during his

frequent nightmares. The nurses most helpful response is to explain that nightmares are:

A normal extension of the childs fear of mutilation

An abnormal response to repressed feelings

A common result of latent sexuality

A side effect of overactivity and stimulation

The nurse suggests an appropriate toy for a hospitalized 6-year-old boy would be a:

Game Boy game

Compact disc player

Adventure book

Game Boy game

Compact disc player

Adventure book

Jigsaw puzzle

The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon

be starting first grade. The nurse determines that the parents understood the information when

the girls father states:

We should put a stop to her thumb-sucking.

Well have a talk about what school is like.

We will let her walk to the bus stop by herself.

Well have her meet some children who will be in her class.

A 9-year-old boy is often cranky and irritable and his school performance has declined. All the

options are true about the child. The possible factor causing this behavior is that he:

Sleeps only 6 to 7 hours a night

Eats eggs every day

Has a new dog

Plays about 1 to 3 hours each evening

A parent asked the nurse, At what age are children capable of assuming more responsibility

for personal belongings? Based on a knowledge of growth and development, the nurse would

respond:

6 years

7 years

9 years

12 years

The school nurse who is preserving a tooth that was knocked out on the school yard will be

especially careful to:

Wrap the tooth loosely in a clean cloth.

Rinse the tooth with alcohol.

Handle the tooth only by the crown.

Place the tooth in a warm environment.

A parent states, My 7-year-old really wants a dog. His 10-year-old brother has allergies to

animal dander. I dont know what to do. The nurse could advise this parent to:

Choose a small breed of dog because the large dogs produce more allergens.

An older unneutered dog produces fewer allergens than a younger one.

A cat may be a good choice since it requires less care and is less allergenic.

Poodles do not shed, making this dog a good choice for people with allergies.

A cat may be a good choice since it requires less care and is less allergenic.

Poodles do not shed, making this dog a good choice for people with allergies.

When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in

the school band and I take tennis lessons. The nurse knows these activities will help this child

develop a sense of:

Initiative

Industry

Identity

Intimacy

A mother reports that she has a new job and her 12-year-old child is home alone for a time

after school. The statement made by the parent, indicating a potentially unsafe situation for this

child, is:

I told him that he could invite a few friends after school.

I put a list of emergency numbers next to the telephone.

Last week we made a first aid kit together.

There is a neighbor available in case of an emergency.

A mother is concerned because her 9-year-old has developed the habit of twitching his eyes

and flipping his hair while communicating with anyone. The best nursing response to this parent

is:

This may indicate that he needs eyeglasses.

Children sometimes do these things for attention.

This behavior suggests low self-esteem.

Tics appear when a child is under stress.

A seventh-grade girl tells the school nurse that her art teacher, also a female, is her hero. The

most appropriate interpretation of the girls comment is:

The student may be exploring her career options.

The comment is cause for concern about sexual abuse.

The child may have difficulty interacting with her peers.

Hero worship is a normal phenomenon.

The comment is cause for concern about sexual abuse.

The child may have difficulty interacting with her peers.

Hero worship is a normal phenomenon.

According to Piaget, a 9-year-old child is in which stage of cognitive development?

Formal operations

Preoperational

Concrete operations

Sensorimotor

The nurse assesses that the 11-year-old has moved from the mind set of egocentrism when he

says:

I am a member of the best Cub Scout group in the world.

I must do my homework before I can play.

My dad can do anything!

Im sorry. I bet that hurt your feelings.

When the school-age child becomes frustrated with a school assignment and says, I cant do

this!, the parent should:

Ask, What is it that is so difficult?

Allow the child to quit the effort.

Call in older siblings to help.

Finish the project for him.

MULTIPLE RESPONSE

The nurse, in attempting to help a 7-year-old girl express her feelings about being in a new

school, would prompt the child with basic feeling words, such as:

Select all that apply.

Mad

Glad

Sad

Scared

Jealous

Mad

Glad

Sad

Scared

Jealous

COMPLETION

The nurse advises the parents of a 6-year-old to try and ensure at least

____________________ hours of sleep daily.

The nurse reminds the parents who are trying to select a dog for their allergic child that the

best selection would be a female dog that is ____________________ and

____________________.

When the fifth-grade class collected geckos in a special aquarium in the classroom, the school

nurse cautioned the teacher to be alert for symptoms of ____________________ that can be

carried by the reptiles.

The pediatric nurse assesses the child who has been diagnosed with diabetes to ensure that he

does to come to believe that his disease is a form of ____________________.

ANS: punishment

Chapter 29 Growth and Development of the Adolescent

When assessing a 13-year-old boy, the nurse would keep in mind physical changes in the

pubertal male, beginning with:

Development of axillary and facial hair

Enlargement of pectoral muscles

Enlargement of testicles

Voice changes

A 13-year-old boy states, The girls in my class tower over me. The nurses most informative

response would be:

It may seem that way because girls have a growth spurt 2 years earlier than

boys.

Perhaps your parents are not exceptionally tall.

Boys usually experience a growth spurt 1 year earlier than girls.

You may feel short, but you are actually average height for your age.

A parent comments that her adolescent daughter seems to be daydreaming a lot these days.

The nurse understands that this behavior indicates she is:

Bored

Not getting enough rest

Trying to block out stress and anxiety

Mentally preparing for real situations

Bored

Not getting enough rest

Trying to block out stress and anxiety

Mentally preparing for real situations

The nurse planning a safety program for high school students should understand that most

accidental deaths in adolescence are related to:

Firearms

Automobiles

Drowning

Diving injuries

A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response

represents an effective problem-solving approach for his parents?

Your studies are too important for you to have a part-time job.

When we went to high school, academics were the teenagers priority.

We want you to put your earnings in a savings account.

How do you think you will manage your school work and a job?

One psychosocial task of adolescence on which the nurse must focus when planning care, is

the development of a sense of:

Initiative

Industry

Identity

Involvement

A 13-year-old female tells the school nurse that she is getting fat, especially in her hips and

legs. The understanding by the nurse that would best guide the response is:

Many teenagers are unaware of proper nutrition.

Teenagers of this age become less active and should eat fewer calories.

c.Puberty is often preceded by fat deposits in these areas.

As soon as menarche occurs, she will lose this excess weight.

Many teenagers are unaware of proper nutrition.

Teenagers of this age become less active and should eat fewer calories.

Puberty is often preceded by fat deposits in these areas.

As soon as menarche occurs, she will lose this excess weight.

The school nurse is planning a program for girls about the physical changes of puberty; this

program should be directed to girls of the age:

16 years

14 years

12 years

10 years

The statement made by a parent indicating understanding about helping a 13-year-old manage

allowance money is:

I set amounts he can earn for particular chores.

I give him a certain amount of money for each day.

I put money into his bank account each month.

I told him to ask me when he needs money.

The nurse suggests a good dietary source of zinc for an adolescent who is a vegetarian would

be:

Green, leafy vegetables

Citrus fruits

Nuts

Enriched breads

An adolescents parent comments, My son seems so preoccupied with his appearance these

days. Is this normal? The nurses best response would be:

It is his attempt to express his individualism.

His preoccupation with his looks is quite normal.

He is probably troubled with his physical changes.

This shows that he has a positive self-image.

It is his attempt to express his individualism.

His preoccupation with his looks is quite normal.

He is probably troubled with his physical changes.

This shows that he has a positive self-image.

Foods that would be a healthy choice for an adolescent who just finished playing in a

strenuous game would be:

Cheeseburger and soda

Hot fudge sundae

Two Egg McMuffins and orange juice

Bagel and skim milk

When planning to answer a 16-year-old girls questions about menstruation, the nurse must

consider cognitive development. According to Piaget, the cognitive aspect that is developed

during adolescence is the ability to:

View a situation from multiple perspectives

Focus more on the past than present situations

Exercise concrete reasoning

Consider hypothetical situations

A girl tells the nurse that she and her best friend belong to the popular clique. She states, I

love Britney Spears and I want to be a singer. The nurse recognizes the girls statement as

characteristic of peer relationships in:

Early adolescence

Middle adolescence

Late adolescence

Entire adolescent period

The nurse is leading a discussion group with parents of adolescents. One parent comments,

My son cant do anything without checking with his friends first. My opinion doesnt count

anymore. The nurse would formulate a response on the knowledge that this behavior is:

Unusual for adolescent boys

Often more apparent in boys than girls

A normal phenomenon during adolescence

Suggestive of feelings of low self-worth

Unusual for adolescent boys

Often more apparent in boys than girls

A normal phenomenon during adolescence

Suggestive of feelings of low self-worth

The nurse points out to a group of parents that the most positive developmental significance

of a peer group to the adolescent is that the group serves as:

A social outlet

An association to blur personal identity

A platform for group think

An initial separation from family

The nurse understands that the adolescents avid sexual orientation to be based on Freuds

theory, which describes adolescence as the _____ stage.

Conceptual

Genital

Glandular

Pubertal

Chapter 30 Atraumatic Care of Children and Families

The nurse assessing a newborn recognizes a sign of hypoglycemia, which is:

Increased respiratory rate

Increased temperature

Active muscle tone

High-pitched cry

The nurse assessing the fundus of the uterus immediately after delivery would expect to find

the uterus:

Well-contracted with its upper border at or just below the umbilicus

Well-contracted with its upper border three or four fingerbreadths above the

umbilicus

Relaxed with its upper border level with the umbilicus

Relaxed with its upper border two or three fingerbreadths below the umbilicus

The statement made by a new mother that indicates she needs additional information about

breastfeeding is:

I let the baby nurse 10 to 15 minutes on the first breast and then switch to the

other breast.

The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.

The baby has been nursing every 2 to 3 hours.

If the baby gets fussy between feedings, I give her a bottle of water.

Following delivery, the nurses assessment reveals a soft, boggy uterus located above the level

of the umbilicus. The appropriate intervention is to:

Notify the doctor

Massage the fundus

Initiate measures that encourage voiding

Position the patient flat

The nurse assesses the initial lochia postdelivery, which is:

Serosa

Rubra

Alba

Vaginalis

Serosa

Rubra

Alba

Vaginalis

A woman will be discharged 48 hours after a vaginal delivery. When planning discharge

teaching, the information the nurse would include about lochia is:

Lochia should disappear 2 to 4 weeks postpartum.

It is normal for the lochia to have a slightly foul odor.

A change in lochia from pink to bright red should be reported.

A decrease in flow will be noticed with ambulation and activity.

The nurse should teach the postpartum woman about perineal self-care by instructing her to:

Perform perineal self-care at least twice a day

Cleanse with warm water in a squeeze bottle from front to back

Remove perineal pads from the rectal area toward the vagina

Use cool water to decrease edema of the perineum

The nurse can expect which of the following interventions to be ordered if the postpartum

woman is not immune to rubella?

The rubella virus vaccine should be administered before discharge.

The woman should receive the rubella virus vaccine at her 6-week postpartum

checkup.

The woman should be instructed not to get pregnant until she receives the

rubella vaccine.

No intervention is indicated at this time because the woman is not at risk for

rubella.

The statement that indicates the new mother is breastfeeding correctly is:

I will put the baby first on the breast that she took last in the previous feeding.

I keep the baby on a 4-hour feeding schedule.

I let the baby stay on the first breast for 20 minutes.

I put only the nipple in the babys mouth when I am breastfeeding.

I will put the baby first on the breast that she took last in the previous feeding.

I keep the baby on a 4-hour feeding schedule.

I let the baby stay on the first breast for 20 minutes.

I put only the nipple in the babys mouth when I am breastfeeding.

The nurse counseling a lactating mother about diet would include instructions to:

Consume 500 more calories than her usual prepregnancy diet.

Eat less meat and more fruits and vegetables.

Drink 3 to 4 tall glasses of fluid daily.

Eat 1,000 more calories than her usual prepregnancy diet.

When a woman asks about resumption of her menstrual cycle after childbirth, the nurse

responds that:

A woman will not ovulate in the absence of menstrual flow.

Most nonlactating women resume menstruation about 2 months postpartum.

Generally, a woman does not ovulate in the first few cycles after childbirth.

The return of menstruation is delayed when a woman does not breastfeed.

The nurse explains that the physician will order RhoGAM in the event that a/an:

Unsensitized Rh-negative mother has an Rh-positive pregnancy.

Rh-negative mother becomes sensitized.

Sensitized infant has a rising bilirubin level.

Unsensitized infant exhibits no outward signs.

After birth, the nurse quickly dries and wraps the newborn in a blanket to prevent heat loss

by:

Conduction

Radiation

Evaporation

Convection

Radiation

Evaporation

Convection

The nurses instructions for a new mother to care for the babys umbilical cord will include:

The area should be kept covered with a sterile dressing.

Clean the stump with alcohol at every diaper change.

Keep the clamp on until the cord falls off.

Give the newborn a daily tub bath until the cord falls off.

A new mother states her preference to formula-feed her newborn. The nurse planning

discharge instructions would tell her about a measure to help suppress lactation and promote

comfort, which is:

Wear a well-fitting bra continuously for several days.

Stand in a warm shower, letting the water spray over the breasts.

Express small amounts of milk from the breasts several times a day.

Massage the breasts when they ache.

On the second postpartum day, a mother bathed her newborn for the first time. She tells the

nurse, I dont think I did it right. Based on the mothers comment, she is most likely in the

postpartum psychological stage of:

Taking in

Taking hold

Letting go

Settling down

A primipara tells the nurse, My afterpains get worse when I am breastfeeding. The most

appropriate nursing response would be:

Ill get you some aspirin to relieve the cramping that you feel.

Afterpains are more intense with your first baby.

Breastfeeding releases a hormone that causes your uterus to contract.

A change of position when youre breastfeeding might help.

Afterpains are more intense with your first baby.

Breastfeeding releases a hormone that causes your uterus to contract.

A change of position when youre breastfeeding might help.

A new mother has decided not to breastfeed her newborn. The nurse planning to teach the

mother about formula feeding would include:

Position the bottle so that the nipple is full of formula during the entire feeding.

Infant formula can be heated safely in a microwave.

Burp the baby after 4 ounces and again when the bottle is empty.

Do not prop a bottle for a feeding until the baby is older.

In the recovery room, the nurse checks the newly delivered womans fundus following a

cesarean section. How would the nurse proceed with this assessment?

Palpate from the midline to the side of body

Palpate from the symphysis to the umbilicus

Palpate from the side of the uterus to the midline

Massage the abdomen in a circular motion

The nurse instructed a postpartum woman about storing and freezing breast milk. The nurse

determines that the teaching was effective when the woman says:

I can thaw frozen breast milk in the microwave.

Ill put enough breast milk for one day in a container.

Breast milk can be stored in glass containers.

Breast milk can be kept in the refrigerator for up to 3 months.

While instructing a new mother on formula preparation, the nurse will include information

about formula choices, such as:

Select all that apply.

Ready-to-feed formula

Concentrated liquid formula

Powdered formula

Cows milk

Canned evaporated milk

Ready-to-feed formula

Concentrated liquid formula

Powdered formula

Cows milk

Canned evaporated milk

COMPLETION

The nurse assesses a 6-inch stain of rubra lochia on a pad that was worn for 2 hours. The nurse

would document this as a ____________________ amount of lochia.

The nurse explains that the only absolute contraindication for a mother to breastfeed her child

is ____________________ infection.

Chapter 31 Health Supervision & Chapter 32 Health Assessment of Children

MULTIPLE CHOICE

The nurse percussing over an empty stomach expects to hear which sound?

Tympany

Resonance

Flatness

Dullness

You are the nurse admitting a toddler to the pediatric infectious disease unit. What is the

single most important component of the childs physical examination?

Assessment of heart and lungs

Measurement of height and weight

Documentation of parental concerns

Obtaining an accurate history

In which section of the health history should the nurse record that the parent brought the infant

to the clinic today because of frequent diarrhea?

Review of systems

Chief complaint

Lifestyle and life patterns

Health history

Which choice includes the components of a complete pediatric history?

Statistical information, client profile, health history, family history, review of

systems, lifestyle and life patterns

Vital signs, chief complaint, and list of previous problems

Chief complaint, including body location, quality, quantity, timeframe, and

alleviating and aggravating factors

Pertinent developmental and family information

The nurse is performing a comprehensive physical examination on a young child in the

hospital. At what age can the nurse expect a childs head and chest circumferences to be almost

equal?

Birth

6 months

1 year

3 years

An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most

appropriate nursing action is to

Ask her why she wants to know.

Determine why she is so anxious.

Explain in simple terms how it works.

Tell her she will see how it works as it is used.

Determine why she is so anxious.

Explain in simple terms how it works.

Tell her she will see how it works as it is used.

Which chart should the nurse use to assess the visual acuity of an 8-year-old child?

Lea chart

Snellen chart

HOTV chart

Tumbling E chart

Which action is appropriate when the nurse is assessing breath sounds of an 18-month-old

crying child?

Ask the parent to quiet the child so the nurse can listen.

Auscultate breath sounds and chart that the child was crying.

Encourage the child to play with the stethoscope to distract and to calm down

before auscultating.

Document that data are not available because of noncompliance.

The nurse is obtaining vital signs on a 1-year-old child. What is the most appropriate site for

assessing the pulse rate?

Apical

Radial

Carotid

Femoral

A nurse is reviewing pediatric physical assessment techniques. Which statement about

performing a pediatric physical assessment is correct?

Physical examinations proceed systematically from head to toe unless

developmental considerations dictate otherwise.

The physical examination should be done with parents in the examining room

for children of any age.

Measurement of head circumference is done until the child is 5 years old.

The physical examination is done only when the child is cooperative.

What term should be used in the nurses documentation to describe auscultation of breath

sounds that are short, popping, and discontinuous on inspiration?

Pleural friction rub

Bronchovesicular sounds

Crackles

Wheeze

Which strategy is the best approach when initiating the physical examination of a 9-monthold

male infant?

Undress the infant and do a head-to-toe examination.

Have the parent hold the child on his or her lap.

Put the infant on the examination table and begin assessments at the head.

d.Ask the parent to leave because the infant will be upset.

Have the parent hold the child on his or her lap.

Put the infant on the examination table and begin assessments at the head.

Ask the parent to leave because the infant will be upset.

Which strategy is not always appropriate for pediatric physical examination?

Take the history in a quiet, private place.

Examine the child from head to toe.

Exhibit sensitivity to cultural needs and differences.

Perform frightening procedures last.

Which assessment should the nurse perform last when examining a 5-year-old child?

Heart

Lungs

Abdomen

Throat

When is the most appropriate time to inspect the genital area during a well-child examination

of a 14-year-old girl?

It is not necessary to inspect the genital area.

Examine the genital area first.

After the abdominal assessment.

Do the genital inspection last.

Which measurement is not indicated for a 4-year-old well-child examination?

Blood pressure

Weight

Height

Head circumference

The nurse inspecting the skin of a dark-skinned child notices an area that is a dusky red or

violet color. This skin coloration is associated with what?

Cyanosis

Erythema

Vitiligo

Nevi

The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was

closed. What does this finding indicate?

This is a normal finding.

This finding indicates premature closure of cranial sutures.

This is abnormal and the child should have a developmental evaluation.

This is an abnormal finding and the child should have a neurologic evaluation.

The nurse is assessing a 4-year-old childs visual acuity. He is planning to attend preschool

next week. The results indicate a visual acuity of 20/40 in both eyes. The childs father asks the

nurse about his sons results. Which response, if made by the nurse, is correct?

Your child will need a referral to the ophthalmologist before he can attend

preschool next week.

Your childs visual acuity is normal for his age.

The results of this test indicate your child may be color blind.

Your child did not pass the screening test. He will need to return within the next

few weeks to be reevaluated.

When interviewing the mother of a 3-year-old child, the nurse asks about developmental

milestones such as the age of walking without assistance. This should be considered

Unnecessary information, because the child is 3 years old

b.An important part of the family history

An important part of the childs past growth and development

An important part of the childs review of systems

Unnecessary information, because the child is 3 years old

An important part of the family history

An important part of the childs past growth and development

An important part of the childs review of systems

Which cranial nerve is assessed when the child is asked to imitate the examiners wrinkled

frown, wrinkled forehead, smile, and raised eyebrow?

Accessory

Hypoglossal

Trigeminal

Facial

Which assessment finding is considered a neurologic soft sign in a 7-year-old child?

Plantar reflex

Poor muscle coordination

Stereognostic function

Graphesthesia

Which parameter correlates best with measurements of the bodys total muscle-mass to fat

ratio?

Height

Weight

Skin-fold thickness

Mid arm circumference

Which tool measures body fat most accurately?

Stadiometer

Calipers

Cloth tape measure

Paper or metal tape measure

When palpating the childs cervical lymph nodes, the nurse notes that they are tender,

enlarged, and warm. What is the best explanation for this?

Some form of cancer

Local scalp infection common in children

Infection or inflammation distal to the site

Infection or inflammation close to the site

What heart sound is produced by vibrations within the heart chambers or in the major arteries

from the back-and-forth flow of blood?

S1, S2

b.S3, S4

Murmur

Physiologic splitting

S1, S2

S3, S4

Murmur

Physiologic splitting

Examination of the abdomen is performed correctly by the nurse in which order?

Inspection, palpation, and auscultation

Palpation, inspection, and auscultation

Palpation, auscultation, and inspection

Inspection, auscultation, and palpation

The nurse has a 2-year-old boy sit in tailor position during palpation for the testes. What is

the rationale for this position?

It prevents cremasteric reflex.

Undescended testes can be palpated.

This tests the child for an inguinal hernia.

The child does not yet have a need for privacy.

During examination of a toddlers extremities, the nurse notes that the child is bowlegged.

The nurse should recognize that this finding is

Abnormal, requiring further investigation

Abnormal unless it occurs in conjunction with knock-knee

Normal if the condition is unilateral or asymmetric

Normal, because the lower back and leg muscles are not yet well developed

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the

finger-to-nose test. The nurse is testing for

Deep tendon reflexes

Cerebellar function

Sensory discrimination

Ability to follow directions

Chapter 33 Caring for Children in Diverse Settings

MULTIPLE CHOICE

Which situation poses the greatest challenge to the nurse working with a child and family?

Twenty-four-hour observation

Emergency hospitalization

Outpatient admission

Rehabilitation admission

MSC: Client Needs: Safe and Effective Care Environment

What is the primary disadvantage associated with outpatient and day facility care?

Increased cost

Increased risk of infection

Lack of physical connection to the hospital

Longer separation of the child from family

Based on concepts related to the normal growth and development of children, which child

would have the most difficulty with separation from family during hospitalization?

A 5-month-old infant

A 15-month-old toddler

c.A

4-year-old child

A 7-year-old child

A 5-month-old infant

A 15-month-old toddler

A 4-year-old child

A 7-year-old child

What is the best explanation for a 2-year-old child who is quiet and withdrawn on the fourth

day of a hospital admission?

The child is protesting her separation from her caregivers.

The child has adjusted to the hospitalization.

The child is experiencing the despair stage of separation.

The child has reached the stage of detachment.

The child is experiencing the despair stage of separation.

The child has reached the stage of detachment.

A 3-year-old child cries, kicks, and clings to the father when the parents try to leave the

hospital room. What is the nurses best response to the parents about this behavior?

Your child is showing a normal response to the stress of hospitalization.

Your child is not coping effectively with hospitalization. Well need to get a

consult from the doctor due to this behavioral problem.

It is helpful for parents to stay with children during hospitalization.

You can avoid this if you leave after your child falls asleep.

Which is the most developmentally appropriate intervention when working with the

hospitalized adolescent?

Encourage peers to call and visit when the adolescents condition allows.

Encourage the adolescents friends to continue with their daily activities; the

adolescent has concrete thinking and will understand.

Discourage questions and concerns about the effects of the illness on the

adolescents appearance.

Ask the parents how the adolescent usually copes in new situations.

The nurse is discussing toddler development with the mother of a 2 1/2-year-old child. Which

statement by the mother indicates she has an understanding of how to help her daughter succeed

in a developmental task while hospitalized?

I always help my daughter complete tasks to help her achieve a sense of

accomplishment.

I provide many opportunities for my daughter to play with other children her

age.

I consistently stress the difference between right and wrong to my daughter.

I encourage my daughter to do things for herself when she can.

Which intervention helps a hospitalized toddler feel a sense of control?

Assign the same nurses to care for the child.

Put a cover over the childs crib.

Require parents to stay with the child.

Follow the childs usual routines for feeding and bedtime.

Why is observation for 24 hours in an acute-care setting often appropriate for children?

Longer hospital stays are more costly.

Children become ill quickly and recover quickly.

Children feel less separation anxiety when hospitalized for 24 hours.

Families experience less disruption during short hospital stays.

In which age-group does the childs active imagination during unfamiliar experiences increase

the stress of hospitalization?

Toddlers

Preschoolers

c.School-age children

Adolescents

Preschoolers

School-age children

Adolescents

Having explanations for all procedures and selecting their own meals from hospital menus is

an important coping mechanism for which age-group?

Toddlers

Preschoolers

School-age children

Adolescents

What is the best action for the nurse to take when a 5-year-old child who requires another 2

days of IV antibiotics cries, screams, and resists having the IV restarted?

Exit the room and leave the child alone until he stops crying.

Tell the child big boys and girls dont cry.

Let the child decide which color arm board to use with the IV.

Administer a narcotic analgesic for pain to quiet the child.

What is the best nursing response to the mother of a 4-year-old child who asks what she can

do to help the child cope with a siblings repeated hospitalizations?

Recommend that the child be sent to visit the grandmother until the sibling

returns home.

Inform the parent that the child is too young to visit the hospital.

Assume the child understands that the sibling will soon be discharged because

the child asks no questions.

Help the mother give the child a simple explanation of the treatment, and

encourage the mother to have the child visit the hospitalized sibling.

How should the nurse advise parents whose preschooler used to sleep through the night and

now awakens at intervals after a short hospitalization?

Regressive behavior after a hospitalization is normal and usually short term.

The child is probably expressing anger.

Egocentric behavior often manifests itself when the child is left alone to sleep.

The child is probably feeling pain and needs further evaluation.

Which is an appropriate nursing intervention for the hospitalized neonate?

Assign the neonate to a room with other neonates.

Provide play activities in the hospital room.

Offer the neonate a pacifier between feedings.

Request that parents bring a security object from home.

Which therapeutic approach will best help a 7-year-old child cope with a lengthy course of

intravenous antibiotic therapy?

Arrange for the child to go to the playroom daily.

Ask the child to draw you a picture of himself or herself.

c.Allow the child to participate in injection play.

Give the child stickers for cooperative behavior.

Arrange for the child to go to the playroom daily.

Ask the child to draw you a picture of himself or herself.

Allow the child to participate in injection play.

Give the child stickers for cooperative behavior.

A preschool-aged child tells the nurse I was bad, thats why I got sick. What is the best

rationale for this childs statement?

The child has a fear that mutilation will lead to death.

The childs imagination is very active, and he may believe the illness is a result

of something he did.

The child has a general understanding of body integrity at this age.

The child will not have fear related to an IV catheter initiation but will have fear

of an impending surgery.

The childs imagination is very active, and he may believe the illness is a result

of something he did.

The child has a general understanding of body integrity at this age.

The child will not have fear related to an IV catheter initiation but will have fear

of an impending surgery.

A 3 1/2-year-old child who is toilet trained has had several accidents since hospital

admission. What is the nurses best action in this situation?

Find out how long the child has been toilet trained at home.

Encourage the parents to scold the child.

Explain how to use a bedpan and place it close to the child.

Follow home routines of elimination.

ANS: D

Chapter 34 Caring for the Special Needs Child

MULTIPLE CHOICE

The parents of a school-age child are told that their child is diagnosed with leukemia. As the

nurse caring for this child, what is the expected first response of the parents to the diagnosis of

chronic illness in their child?

Anger and resentment

Sorrow and depression

Shock and disbelief

Acceptance and adjustment

What is the primary concern for the parents of a dying child?

Pain

Safety

Food intake

Fluid intake

An important nursing goal in caring for the hospitalized child is to minimize the negative

effects of illness and hospitalization. On what should the nurse focus while caring for a

hospitalized infant?

Bodily injury and pain

Separation from caregivers and fear of strangers

Loss of control and altered body image

The unknown and being left alone

What corresponds to a 5-year-old childs understanding of death?

Loss of a caretaker

Reversible and temporary

Permanent

Inevitable

You are counseling the family of a 12-month-old child who has lost his mother in a car

accident. How should you explain to the father what the childs understanding of death is, related

to theories of growth and development?

Temporary

Permanent

Loss of caretaker

Punishment

Permanent

Loss of caretaker

Punishment

How can chronic illness and frequent hospitalizations affect the psychosocial development of

a toddler?

They can create a distortion or differentiation of self from parent.

They can interfere with the development of autonomy.

They can interfere with the acquisition of language, fine motor, and self-care

skills.

They can create feelings of inadequacy.

How can chronic illness and frequent hospitalizations affect the psychosocial development of

an adolescent?

They can lead to feelings of inadequacy.

They can interfere with parental attachment.

They can block the development of identity.

They can prevent the development of imagination.

What is an important focus of nursing care for the dying child and his or her family?

Nursing care should be organized to minimize contact with the child.

Adequate oral intake is crucial to the dying child.

Families should be made aware that hearing is the last sense to stop functioning

before death.

It is best for the family if nursing care takes place during periods when the child

is alert.

What is the most appropriate response to a school-age child who asks if she can talk to her

dying sister?

You need to talk loudly so she can hear you.

Holding her hand would be better because at this point she cant hear you.

Although she cant hear you, she can feel your presence so sit close to her.

Even though she will probably not answer you, she can still hear what you say

to her.

What is the priority goal for the child with a chronic illness?

To maintain the intactness of the family

To eliminate all stressors

To achieve complete wellness

To obtain the highest level of wellness

To eliminate all stressors

To achieve complete wellness

To obtain the highest level of wellness

What is the predominant trait of the resilient family associated with chronic illness?

Social separation

Family flexibility

Family cohesiveness

Clear family boundaries

Many parents who have children diagnosed with a chronic illness experience recurrent

feelings of grief, loss, and fear related to the childs condition and loss of the ideal healthy child.

The nurse recognizes this process as

Anticipatory grieving

Chronic sorrow

Bereavement

Illness trajectory

What is a priority nursing diagnosis for the preschool child with chronic illness?

Risk for delayed growth and development related to chronic illness or disability

Chronic pain related to frequent injections

Anticipatory grieving related to impending death

Anxiety related to frequent hospitalizations

Identify the most appropriate response for the nurse when parents say, Living with this

disease is really hard; its not fair.

Tell me about what is hard for you.

I know exactly how you must feel.

I know a local support group for families.

I am going to ask the grief counselor to meet with you.

Identify the most appropriate nursing response to a parent who tells the nurse, I dont want my

child to know she is dying.

I shall respect your decision. I wont say anything to your child.

Dont you think she has a right to know about her condition?

Would you like me to arrange for the physician to speak with your child?

Ill answer any questions she asks me as honestly as I can.

I shall respect your decision. I wont say anything to your child.

Dont you think she has a right to know about her condition?

Would you like me to arrange for the physician to speak with your child?

Ill answer any questions she asks me as honestly as I can.

Which activity should the nurse implement for the toddler hospitalized with a chronic illness

to promote autonomy?

Playing with a push-pull toy

Putting together a puzzle

Playing a simple card game

Watching cartoons on television

Playing a simple card game

Watching cartoons on television

The nurse case manager is planning a care conference about a young child who has complex

health care needs and will soon be discharged home. Who should the nurse invite to the

conference?

Family and nursing staff

Social worker, nursing staff, and primary care physician

Family and key health professionals involved in the childs care

Primary care physician and key health professionals involved in the childs care

Families progress through various stages of reactions when a child is diagnosed with a

chronic illness or disability. After the shock phase, a period of adjustment usually follows. This

is often characterized by which response?

Denial

Guilt and anger

Social reintegration

Acceptance of childs limitations

The nurse comes into the room of a child who was just diagnosed with a chronic disability.

The childs parents begin to yell at the nurse about a variety of concerns. The nurses best response

What is really wrong?

Being angry is only natural.

Yelling at me will not change things.

I will come back when you settle down.

The feeling of guilt that the child caused the disability or illness is especially critical in which

child?

Toddler

Preschooler

School-age child

Adolescent

The nurse is providing support to a family who is experiencing anticipatory grief related to

their childs imminent death. An appropriate nursing intervention is to

Be available to family.

Attempt to lighten the mood.

Suggest activities to cheer up the family.

Discourage crying until actual time of death.

Chapter 35 Key Pediatric Nursing Interventions

MULTIPLE CHOICE

What is the most appropriate statement for the nurse to make to a 5-year-old child who is

undergoing a venipuncture?

You must hold still or Ill have someone hold you down. This is not going to

hurt.

This will hurt like a pinch. Ill get someone to help hold your arm still so it will

be over fast and hurt less.

Be a big boy and hold still. This will be over in just a second.

Im sending your mother out so she wont be scared. You are big, so hold still and

this will be over soon.

Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of

immunosuppression?

Spiritual distress

Social isolation

Deficient diversional activity

Sleep deprivation

Spiritual distress

Social isolation

Deficient diversional activity

Sleep deprivation

What should the nurse consider when having consent forms signed for surgery and procedures

on children?

Only a parent or legal guardian can give consent.

The person giving consent must be at least 18 years old.

The risks and benefits of a procedure are part of the consent process.

A mental age of 7 years or older is required for a consent to be considered

informed.

The person giving consent must be at least 18 years old.

The risks and benefits of a procedure are part of the consent process.

A mental age of 7 years or older is required for a consent to be considered

informed.

The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures.

Guidelines for preparing this preschooler should include

Planning for a short teaching session of about 30 minutes

Telling the child that procedures are never a form of punishment

Keeping equipment out of the childs view

Using correct scientific and medical terminology in explanations

Which nursing action is most appropriate when treating a child who has a fever of 102.5 F?

Restrict fluid intake.

Administer an aspirin.

Administer an antipyretic such as acetaminophen.

Bathe the child in tepid water.

What is the best response for a nurse to make to a parent who has asked, When should I start

dental care for my child?

The recommendation is for children to have a dental examination no later than

2.5 years.

Children should see a dentist at least one time before kindergarten.

The recommendation is for children to have a dental examination before first

grade.

A dental examination by 1 year of age is the current recommendation.

Which action is appropriate to promote a toddlers nutrition during hospitalization?

Allow the child to walk around during meals.

Require the child to empty his or her plate.

Ask the childs parents to bring a cup and utensils from home.

Select new foods for the child from the menu.

The nurse knows that measuring temperature is an integral part of assessment. Which concept

is important for the nurse to know when taking a childs temperature?

The method used should be consistent.

Rectal temperatures should always be taken on infants.

Oral temperatures can be taken on all children older than 5 years of age.

Axillary temperatures should be taken at night.

A parent calls the pediatricians office because her 1-year-old child has a 100 F temperature.

What is the most appropriate initial nursing response to make to the parent?

Did you feel your childs forehead?

b.Tell me about the childs behavior.

Has anyone in your home been sick lately?

There is no need for concern if the childs temperature is less than 101 F.

Did you feel your childs forehead?

Tell me about the childs behavior.

Has anyone in your home been sick lately?

There is no need for concern if the childs temperature is less than 101 F.

What nursing action is appropriate for specimen collection?

Follow sterile technique for specimen collection.

Sterile gloves are worn if the nurse plans to touch the specimen.

Use Standard Precautions when handling body fluids.

Avoid wearing gloves in front of the child and family.

Follow sterile technique for specimen collection.

Sterile gloves are worn if the nurse plans to touch the specimen.

Use Standard Precautions when handling body fluids.

Avoid wearing gloves in front of the child and family.

What information should the nurse include in teaching parents how to care for a childs

gastrostomy tube at home?

Never turn the gastrostomy button.

Clean around the insertion site daily with soap and water.

Expect some leakage around the button.

Remove the tube for cleaning once a week.

Which nursing action is the most appropriate when applying a face mask to a child for

oxygen therapy?

The oxygen flow rate should be less than 6 L/min.

Make sure the mask fits properly.

Keep the child warm.

Remove the mask for 5 minutes every hour.

What is appropriate to include in the care plan for a family of a child with a tracheostomy?

Suction of the tracheostomy every 2 to 4 hours or as needed

Application of powder around the stoma to decrease irritation

Suction catheter insertion limited to less than 30 seconds

Hygiene that includes showers, not baths

Which action by the nurse indicates that the correct procedure has been used to measure vital

signs in a toddler?

Measuring oral temperature for 5 minutes

Counting apical heart rate for 60 seconds

Observing chest movement for respiratory rate

Recording blood pressure as P/80

Which action by the nurse is appropriate when preparing a child for a procedure?

Discourage the child from crying during the procedure.

Use professional terms so the child will understand what is happening.

Give the child choices whenever possible.

Discourage the parents from staying in the room during the procedure.

The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse she

wants her mother with her like before. The most appropriate nursing action is to

Grant her request.

Explain why this is not possible.

Identify an appropriate substitute for her mother.

Offer to provide support to her during the procedure.

Grant her request.

Explain why this is not possible.

Identify an appropriate substitute for her mother.

Offer to provide support to her during the procedure.

The nurse wore gloves during a dressing change. When the gloves are removed, the nurse

should

Wash hands thoroughly.

Check the gloves for leaks.

Use an alcohol-based hand rub.

Apply new gloves before touching the next patient.

An important nursing consideration when performing a bladder catheterization on a young

boy is to

Use clean technique, not Standard Precautions.

Insert 2% lidocaine lubricant into the urethra.

Lubricate catheter with water-soluble lubricant such as K-Y Jelly.

Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

Chapter 36 Pain Management in Children

MULTIPLE CHOICE

Childbirth preparation can be considered successful if the outcome is described as

Labor was pain-free.

Birth experiences of friends and families were discredited.

The woman rehearsed labor and practiced skills to master pain.

Only nonpharmacologic methods for pain control were used.

In order to help patients manage discomfort and pain during labor, nurses should be aware that

The predominant pain of the first stage of labor is the visceral pain located in

the lower portion of the abdomen.

Somatic pain is the extreme discomfort between contractions.

The somatic pain of the second stage of labor is more generalized and related to

fatigue.

Pain during the third stage is a somewhat milder version of the second stage.

The nurse caring for women in labor understands that childbirth pain is different from other

types of pain in that it is

More responsive to pharmacologic management

Associated with a physiologic process

Designed to make one withdraw from the stimulus

Less intense

Excessive anxiety in labor heightens the womans sensitivity to pain by increasing

Muscle tension

Blood flow to the uterus

The pain threshold

Rest time between contractions

When providing labor support, the nurse knows that which fetal position might cause the

laboring woman more back discomfort?

Right occiput anterior

Left occiput anterior

Right occiput transverse

Left occiput posterior

Left occiput anterior

Right occiput transverse

Left occiput posterior

It is important for the nurse to develop a realistic birth plan with the pregnant woman. The

nurse can explain that a major advantage of nonpharmacologic pain management is that

More complete pain relief is possible.

No side effects or risks to the fetus are involved.

The woman remains fully alert at all times.

A more rapid labor is likely.

The best time to teach nonpharmacologic pain control methods to an unprepared laboring

woman is during which phase?

Latent phase

Active phase

Transition phase

Second stage

The nurse providing newborn stabilization must be aware that the primary side effect of

maternal narcotic analgesia in the newborn is

Respiratory depression

Bradycardia

Acrocyanosis

Tachypnea

A woman received 50 mcg of Fentanyl intravenously 1 hour before delivery. What drug

should the nurse have readily available?

Promethazine (Phenergan)

Nalbuphine (Nubain)

Butorphanol (Stadol)

Naloxone (Narcan)

The nerve block used in labor that provides anesthesia to the lower vagina and perineum is

called a(n)

Epidural

Pudendal

Local

Spinal block

The most important nursing intervention after the injection of epidural anesthesia is

monitoring

Urinary output

Contractions

Maternal blood pressure

d.Intravenous infusion rate

Which statement is true about the physiologic effects of pain in labor?

It usually results in a more rapid labor.

It is considered to be a normal occurrence.

It may result in decreased placental perfusion.

It has no effect on the outcome of labor.

Which woman will most likely have increased anxiety and tension during her labor?

Gravida 1 who did not attend prepared childbirth classes

Gravida 2 who refused any medication

Gravida 2 who delivered a stillborn baby last year

Gravida 3 who has two children younger than 3 years

Which method of pain management is safest for a gravida 3 para 2 admitted at 8 cm cervical

dilation?

Epidural anesthesia

Narcotics

Spinal block

Breathing and relaxation techniques

The laboring woman who imagines her body opening to let the baby out is using a mental

technique called

Dissociation

Effleurage

Imagery

Distraction

When giving a narcotic to a laboring woman, the nurse should inject the medication at the

beginning of a contraction so that

Full benefit of the medication is received during that contraction.

Less medication will be transferred to the fetus.

The medication will be rapidly circulated.

The maternal vital signs will not be adversely affected.

The method of anesthesia in labor considered the safest for the fetus is the

Pudendal block

Epidural block

c.Spinal (

subarachnoid) block

Local infiltration

Pudendal block

Epidural block

Spinal (subarachnoid) block

Local infiltration

To improve placental blood flow immediately after the injection of an epidural anesthetic, the

nurse should

Turn the woman to the right side.

Place a wedge under the womans right hip.

Give the woman oxygen.

Decrease the intravenous infusion rate.

The most important nursing intervention for the patient who has received an epidural narcotic

Monitoring respiratory rate hourly

Administering analgesics as needed

Monitoring blood pressure every 4 hours

Assessing the level of anesthesia

One of the greatest risks to the mother during administration of general anesthesia is

Respiratory depression

Uterine relaxation

Inadequate muscle relaxation

Aspiration of stomach contents

To provide optimal care to the intrapartum woman, the nurse understands that the least

favorable maternal position for labor is

Supine

Sitting

Lying on the side

Standing

A newborn infant weighing 8 lb (3632 g) needs naloxone (Narcan). This infant should

receive approximately _____ mg.

0.36

3.6

0.03

0.3

To assist the woman after delivery of the infant, the nurse knows that the blood patch is used

after spinal anesthesia to relieve

Hypotension

Headache

Neonatal respiratory depression

Loss of movement

Headache

Neonatal respiratory depression

Loss of movement

What is the first type of breathing technique used in labor?

Slow-paced

Modified-paced

Patterned-paced

Pant-blow

When instructing the woman in early labor, the nurse teaches her that an important aspect of

proper breathing technique is

Breathing no more than three times the normal rate

Beginning and ending with a cleansing breath

Holding the breath no longer than 10 seconds

Adhering exactly to the techniques as they were taught

Chapter 37 Nursing Care of the Child With an Infectious or Communicable Disorder

MULTIPLE CHOICE

The nurse takes into consideration that the child most susceptible to an opportunistic infection

is the one taking:

Anticonvulsants

A beta-adrenergic agent

An antibiotic

Corticosteroids

When the 8-year-old asks the nurse how she got the antibodies that kept her from getting

whooping cough, the nurse explains that those shots:

Were borrowed antibodies from another person who had whooping cough

Gave her a tiny case of whooping cough and then she made her own antibodies

Strengthened antibodies she was born with

Are only temporary borrowed antibodies and she needs to have another shot

every 5 years

The nurse would document a rash that has erythematous circular raised lesions as:

Macular

Papular

Vesicular

Pustular

Macular

Papular

Vesicular

Pustular

The nurse would delay the administration of DTaP when the mother says that her infant:

Has diarrhea

Had a temperature of 105 F from the previous inoculation

Is teething

Is traveling with her to Europe in a week

The type of precaution that is necessary when caring for a toddler with varicella is:

Contact

Protective

Airborne infection

Large droplet infection

A parent is concerned because her son was exposed to varicella at preschool. The nurse would

tell this parent that the incubation period for varicella is:

2 to 10 days

4 to 14 days

3 to 32 days

14 to 21 days

The nurse can be assured that parents understand how long a child who has varicella is

contagious when they state:

My child should stay home from school for 6 days after the pox appear.

My child can return to school when the rash fades.

My child must stay away from other children until all of the lesions have healed.

My child is contagious as long as he has a fever.

My child should stay home from school for 6 days after the pox appear.

My child can return to school when the rash fades.

My child must stay away from other children until all of the lesions have healed.

My child is contagious as long as he has a fever.

The statement made by a sexually active adolescent girl indicating an understanding of the

prevention of sexually transmitted diseases is:

I always douche after intercourse.

I think you can get a vaccination for STDs now.

I insist that my partner wear a condom.

I am protected because I take the pill.

The priority nursing diagnosis for a hospitalized infant who is HIV-positive would be:

Risk for injury

Altered nutrition

Impaired skin integrity

Risk for infection

A parent of a newborn asked the nurse, When will my baby get the hepatitis B vaccine? The

nurse bases a response on the knowledge that the first dose of Comvax should be given to infants

born to a hepatitis B-negative mother at:

2 months

4 months

6 months

1 year

The nurse would base a response to a parent about how his child got hepatitis A on the

information that the child:

Came in contact with infected blood

Came in contact with droplets in the air

Was bitten by a mosquito or a tick

Ate shrimp while they were in Mexico

Came in contact with infected blood

Came in contact with droplets in the air

Was bitten by a mosquito or a tick

Ate shrimp while they were in Mexico

An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse

use when caring for the infant?

Large-droplet infection precautions

Airborne-infection precautions

Contact precautions

Protective precautions

A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the

most appropriate response for the nurse to make when the child asks, Why do you have to wear a

gown and mask when you are in my room?

Nurses and doctors wear gowns and masks because you have a condition that

could be spread to others.

The gown and mask are to protect you because you could get an infection very

easily.

Im wearing this because there are a lot of bacteria in the hospital.

I might look scary but you wont need this after you have had medication for 24

hours.

The nurse is planning to administer immunizations at a well-child visit when a parent reports

the 18-month-old child is allergic to eggs. The vaccine that would be contraindicated is:

Influenza

Inactivated polio vaccine

Diphtheria, tetanus, acellular pertussis

Hepatitis B

The nurse would choose to administer the immunization injection of:

DTaP subcutaneously

Hib vaccine prepared in a separate syringe

c.Varicella intramuscularly

Varicella 1 week after the MMR vaccine

DTaP subcutaneously

Hib vaccine prepared in a separate syringe

Varicella intramuscularly

Varicella 1 week after the MMR vaccine

A child was sent to the school nurse because of a rash. The nurse noted the rash was present

on the trunk, extremities, and face. The childs cheeks were bright red. The nurse is aware this

type of rash is consistent with:

Measles

Roseola

Varicella

Fifth disease

The nurse determined the parent understood the information when he stated:

Ill have my son wear dark clothing on his hike.

We should all get the Lyme disease vaccine before our trip.

Ill get a prescription for amoxicillin to take with us.

We will wear long pants and long-sleeved shirts in the woods.

An adolescent is taking tetracycline for a sexually transmitted disease. The nurse would

stress in the instruction about this medication to:

Finish all of the medication.

Get plenty of fresh air and sunlight.

The medication should be taken with food.

Take an antacid if the medication causes an upset stomach.

Chapter 38 Nursing Care of the Child With Alteration in Intracranial Regulation/Neurologic Disorder

MULTIPLE CHOICE

What is a sign of increased intracranial pressure (ICP) in a 10-year-old child?

Headache

Bulging fontanel

Tachypnea

Increase in head circumference

Which information should the nurse give to a child who is to have magnetic resonance

imaging (MRI) of the brain?

Your head will be restrained during the procedure.

You will have to drink a special fluid before the test.

You will have to lie flat after the test is finished.

You will have electrodes placed on your head with glue.

Which term is used when a patient remains in a deep sleep, responsive only to vigorous and

repeated stimulation?

Coma

Stupor

Obtundation

Persistent vegetative state

The Glasgow Coma Scale consists of an assessment of

Pupil reactivity and motor response

Eye opening and verbal and motor responses

Level of consciousness and verbal response

ICP and level of consciousness

Nursing care of the infant who has had a myelomeningocele repair should include

Securely fastening the diaper

Measurement of pupil size

Measurement of head circumference

Administration of seizure medications

The most common problem of children born with a myelomeningocele is

Neurogenic bladder

Intellectual impairment

Respiratory compromise

Cranioschisis

Neurogenic bladder

Intellectual impairment

Respiratory compromise

Cranioschisis

A recommendation to prevent neural tube defects is the supplementation of

Vitamin A throughout pregnancy

Multivitamin preparations as soon as pregnancy is suspected

Folic acid for all women of childbearing age

d.Folic acid during the first and second trimesters of pregnancy

Multivitamin preparations as soon as pregnancy is suspected

Folic acid for all women of childbearing age

Folic acid during the first and second trimesters of pregnancy

How much folic acid is recommended for women of childbearing age?

1.0 mg

0.4 mg

1.5 mg

2.0 mg

ANS: B

Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions

include

Avoiding using any latex product

Using only nonallergenic latex products

Administering medication for long-term desensitization

Teaching family about long-term management of asthma

When a 2-week-old infant is seen for irritability, poor appetite, and rapid head growth with

observable distended scalp veins, the nurse recognizes these signs as indicative of

Hydrocephalus

Syndrome of inappropriate antidiuretic hormone (SIADH)

Cerebral palsy

Reyes syndrome

What finding should cause the nurse to suspect a diagnosis of spastic cerebral palsy?

Tremulous movements at rest and with activity

Sudden jerking movement caused by stimuli

Writhing, uncontrolled, involuntary movements

Clumsy, uncoordinated movements

Which finding in an analysis of cerebrospinal fluid (CSF) is consistent with a diagnosis of

bacterial meningitis?

CSF appears cloudy.

CSF pressure is decreased.

Few leukocytes are present.

Glucose level is increased compared with blood.

How should the nurse explain positioning for a lumbar puncture to a 5-year-old child?

You will be on your knees with your head down on the table.

You will be able to sit up with your chin against your chest.

c.You will be on your side with the head of your bed slightly raised.

You will lie on your side and bend your knees so that they touch your chin.

You will be on your knees with your head down on the table.

You will be able to sit up with your chin against your chest.

You will be on your side with the head of your bed slightly raised.

You will lie on your side and bend your knees so that they touch your chin.

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

A mother reports that her child has episodes where he appears to be staring into space. This

behavior is characteristic of which type of seizure?

Absence

Atonic

Tonic-clonic

Simple partial

What is the best response to a father who tells the nurse that his son daydreams at home and

his teacher has observed this behavior at school?

Your son must have an active imagination.

Can you tell me exactly how many times this occurs in one day?

Tell me about your sons activity when you notice the daydreams.

He is probably overtired and needs more rest.

The nurse teaches parents to alert their health care provider about which adverse effect when

a child receives valproic acid (Depakene) to control generalized seizures?

Weight loss

Bruising

Anorexia

Drowsiness

A child with a head injury sleeps unless aroused, and when aroused responds briefly before

falling back to sleep. What should the nurse chart for this childs level of consciousness?

Disoriented

Obtunded

Lethargic

Stuporous

Which type of fractures describes traumatic separation of cranial sutures?

Basilar

Linear

Commuted

Depressed

Chapter 39 Nursing Care of the Child With Alteration in Sensory Perception/Disorder of Eyes or Ears

MULTIPLE CHOICE

A parent comments that her infant has had several ear infections in the past few months. The

nurse understands that infants are more susceptible to otitis media because:

Infants are in a supine or prone position most of the time.

Sucking on a nipple creates middle ear pressure.

They have increased susceptibility to upper respiratory tract infections.

The eustachian tube is short, straight, and wide.

The nurse determines a mother understands instructions about administering an oral antibiotic

for otitis media when the mother verbalizes that she will:

Continue using the medication until symptoms are relieved.

Share the medicine with siblings if their symptoms are the same.

Give the medication with a glass of milk.

Administer prescribed doses until all the medication is used.

The situation in which the nurse would be suspicious about a hearing impairment is:

A 3-month-old infant with a positive Moro reflex

A 15-month-old toddler who is babbling

An 18-month-old toddler who is speaking one-syllable words

A 24-month-old toddler who communicates by pointing

The best way for the nurse to communicate with a 10-year-old child who has a hearing

impairment would be to:

Use gestures and signs as much as possible.

Let the childs parents communicate for her.

Face the child and speak clearly in short sentences.

Recognize that the childs ability to communicate will be on a 6-year-old level.

Use gestures and signs as much as possible.

Let the childs parents communicate for her.

Face the child and speak clearly in short sentences.

Recognize that the childs ability to communicate will be on a 6-year-old level.

The nurse planning postoperative teaching for a child who has had a tympanostomy with

insertion of tubes would include:

Keep the infant flat after feeding.

Give over-the-counter anticongestants.

Avoid getting water in the ears.

Clean the ear canal with cotton-tipped applicators.

The school nurse would suspect amblyopia when the child:

Has a reddened sclera in one eye

Covers one eye to read the board

Complains of a headache

Has copious tears while watching TV

The nurse explains that a common treatment for amblyopia is:

Patching the good eye to force the brain to use the affected eye

Patching the affected eye to allow the refractory muscles to rest

Using glasses that will slightly blur the image for the good eye

Using corticosteroids to treat inflammation of the optic nerve

Patching the good eye to force the brain to use the affected eye

Patching the affected eye to allow the refractory muscles to rest

Using glasses that will slightly blur the image for the good eye

Using corticosteroids to treat inflammation of the optic nerve

The school nurse recognizes the cardinal sign of a hyphema when she assesses:

Opacity of the lens

A yellow-white reflex on the pupil

A dark-red spot in front of the iris

Inflamed mucous membranes of the eyelids

The nurse is planning to teach parents about prevention of Reyes syndrome. What information

would the nurse include in this teaching?

Use aspirin instead of acetaminophen for children with viral illness.

Advise parents to have their children immunized against Reyes syndrome.

Avoid giving salicylate-containing medications to a child who has viral

symptoms.

Get the child tested for Reyes syndrome if the child exhibits fever, vomiting,

and lethargy.

The nurse caring for a 5-month-old with viral influenza suspects the development of Reyes

syndrome when the child:

Has respirations drop from 18 to 14 breaths/min

Goes to sleep after feeding

Suddenly vomits

Develops a macular rash

Has respirations drop from 18 to 14 breaths/min

Goes to sleep after feeding

Suddenly vomits

Develops a macular rash

The nurse explains that febrile seizures:

Occur when the body temperature exceeds 103F

Can be prevented by anticonvulsant medication

Usually lead to the development of epilepsy

Occur when the temperature rises quickly

A parent reports that her child experiences episodes where he appears to be staring into

space. This behavior is characteristic of which type of seizure?

Absence

Akinetic

Myoclonic

Complex partial

An adolescent has just had a generalized seizure lasting 1 minute. Following the seizure, the

nurse should:

Help the patient to sit upright

Turn on the side

Offer ice chips

Assist to ambulate

Help the patient to sit upright

Turn on the side

Offer ice chips

Assist to ambulate

When a child is experiencing a generalized tonic-clonic seizure, an appropriate nursing

action would be to:

Guide the child to the floor if the child is standing, and then go for help.

Move objects out of the childs immediate area.

Stick a padded tongue blade between the childs teeth.

Manually restrain the child.

A child had a generalized tonic-clonic seizure that lasted 90 seconds. After a generalized

tonic-clonic seizure, the nurse would expect that the child might be:

Restless

Sleepy

Nauseated

Anxious

The nurse would include in a teaching plan pertinent to the long-term administration of

Dilantin that:

The medication should be given with food to reduce gastrointestinal distress.

Behavioral changes are a possible side effect.

c.Gums should be massaged regularly to prevent hyperplasia.

Blood pressure should be closely monitored.

Behavioral changes are a possible side effect.

Gums should be massaged regularly to prevent hyperplasia.

Blood pressure should be closely monitored.

The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the

child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has

which type of cerebral palsy?

Athetoid

Ataxic

Spastic

Mixed

The assessment finding that should be reported immediately if observed in a child with

meningitis is:

Irregular respirations

Tachycardia

Slight drop in blood pressure

Elevated temperature

Chapter 40 Nursing Care of the Child With an Alteration in Gas Exchange/Respiratory Disorder

MULTIPLE CHOICE

A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with

purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse

recognizes that these symptoms are characteristic of which respiratory condition?

Allergic rhinitis

Bronchitis

Asthma

d.Sinusitis

Bronchitis

Asthma

Sinusitis

ANS: D

For which problem should the child with chronic otitis media with effusion be evaluated?

Brain abscess

Meningitis

Hearing loss

Perforation of the tympanic membrane

The nurse expects the initial plan of care for a 9-month-old child with an acute otitis media

infection to include

symptomatic treatment and observation for 48 to 72 hours after diagnosis

an oral antibiotic, such as amoxicillin, five times a day for 7 days

pneumococcal conjugate vaccine

myringotomy with tympanoplasty tubes

Which statement made by a parent indicates an understanding about treatment of streptococcal

pharyngitis?

I guess my child will need to have his tonsils removed.

A couple of days of rest and some ibuprofen will take care of this.

I should give the penicillin three times a day for 10 days.

I am giving my child prednisone to decrease the swelling of the tonsils.

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

The father of an infant calls the nurse to his sons room because he is making a strange noise. A

diagnosis of laryngomalacia is made. What does the nurse expect to find on assessment?

Stridor

High-pitched cry

Nasal congestion

Spasmodic cough

The nurse should assess a child who has had a tonsillectomy for

Frequent swallowing

Inspiratory stridor

Rhonchi

Elevated white blood cell count

The parent of a toddler calls the nurse, asking about croup. What is a distinguishing

manifestation of spasmodic croup?

a.Wheezing is heard audibly.

It has a harsh, barky cough.

It is bacterial in nature.

Wheezing is heard audibly.

It has a harsh, barky cough.

It is bacterial in nature.

The child has a high fever.

Which intervention for treating croup at home should be taught to parents?

Have a decongestant available to give the child when an attack occurs.

Have the child sleep in a dry room.

Take the child outside.

Give the child an antibiotic at bedtime.

A 5-year-old child is brought to the emergency department with copious drooling and a

croaking sound on inspiration. Her mother states that the child is very agitated and only wants to

sit upright. What should be the nurses first action in this situation?

Prepare intubation equipment and call the physician.

Examine the childs oropharynx and call the physician.

Obtain a throat culture for respiratory syncytial virus (RSV).

Obtain vital signs and listen to breath sounds.

What intervention can be taught to the parents of a 3-year-old child with pneumonia who is

not hospitalized?

Offer the child only cool liquids.

Offer the child her favorite warm liquid drinks.

Use a warm mist humidifier.

Call the physician for a respiratory rate less than 28 breaths/min.

What sign is indicative of respiratory distress in infants?

Nasal flaring

Respiratory rate of 55 breaths/min

Irregular respiratory pattern

Abdominal breathing

Once an allergen is identified in a child with allergic rhinitis, the treatment of choice about

which to educate the parents is

Using appropriate medications

Beginning desensitization injections

Eliminating the allergen

Removing the adenoids

ANS: C

Which assessment finding after tonsillectomy should be reported to the physician?

Vomiting bright red blood

Pain at surgical site

Pain on swallowing

The ability to only take small sips of liquids

Teaching safety precautions with the administration of antihistamines is important because of

what common side effect?

Dry mouth

Excitability

Drowsiness

Dry mucous membranes

Excitability

Drowsiness

Dry mucous membranes

What is an appropriate beverage for the nurse to give to a child who had a tonsillectomy

earlier in the day?

Chocolate ice cream

Orange juice

Fruit punch

Apple juice

Which type of croup is always considered a medical emergency?

Laryngitis

Epiglottitis

Spasmodic croup

Laryngotracheobronchitis (LTB)

What information should the nurse teach workers at a daycare center about RSV?

RSV is transmitted through particles in the air.

RSV can live on skin or paper for up to a few seconds after contact.

RSV can survive on nonporous surfaces for about 60 minutes.

Frequent handwashing can decrease the spread of the virus.

Which intervention is appropriate for the infant hospitalized with bronchiolitis?

a.Position on the side with neck slightly flexed.

Administer antibiotics as ordered.

Restrict oral and parenteral fluids if tachypneic.

Position on the side with neck slightly flexed.

Administer antibiotics as ordered.

Restrict oral and parenteral fluids if tachypneic.

Give cool, humidified oxygen.

A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase

of respiration. This suggests

Asthma

Pneumonia

Bronchiolitis

Foreign body in trachea

Pneumonia

Bronchiolitis

Foreign body in trachea

The nurse encourages the mother of a toddler with acute LTB to stay at the bedside as much

as possible. The nurses rationale for this action is primarily that

Mothers of hospitalized toddlers often experience guilt.

The mothers presence will reduce anxiety and ease childs respiratory efforts.

Separation from mother is a major developmental threat at this age.

The mother can provide constant observations of the childs respiratory efforts.

Which statement indicates that a parent of a toddler needs more education about preventing

foreign body aspiration?

I keep objects with small parts out of reach.

My toddler loves to play with balloons.

I wont permit my child to have peanuts.

I never leave coins where my child could get them.

What is a common trigger for asthma attacks in children?

Febrile episodes

Dehydration

Exercise

Seizures

Which child requires a Mantoux test?

The child who has episodes of nighttime wheezing and coughing

The child who has a history of allergic rhinitis

The child whose baby-sitter has received a tuberculosis diagnosis

The premature infant who is being treated for apnea of infancy

What explanation should the nurse give to the parent of a child with asthma about using a

peak flow meter?

It is used to monitor the childs breathing capacity.

It measures the childs lung volume.

It will help the medication reach the childs airways.

It measures the amount of air the child breathes in.

It is used to monitor the childs breathing capacity.

It measures the childs lung volume.

It will help the medication reach the childs airways.

It measures the amount of air the child breathes in.

What is the best nursing response to the parent of a child with asthma who asks if his child

can still participate in sports?

Children with asthma are usually restricted from physical activities.

Children can usually play any type of sport if their asthma is well controlled.

Avoid swimming because breathing underwater is dangerous for people with

asthma.

Even with good asthma control, I would advise limiting the child to one athletic

activity per school year.

A school-age child had an upper respiratory tract infection for several days and then began

having a persistent dry, hacking cough that was worse at night. The cough has become

productive in the past 24 hours. This is most suggestive of

Bronchitis

Bronchiolitis

Viral-induced asthma

Acute spasmodic laryngitis

Which classification of drugs is used to relieve an acute asthma episode?

Short-acting beta2-adrenergic agonist

Inhaled corticosteroids

Leukotriene blockers

Long-acting bronchodilators

The nurse getting an end-of-shift report on a child with status asthmaticus should question

which intervention?

Administer oxygen by nasal cannula to keep oxygen saturation at 100%.

Assess intravenous (IV) maintenance fluids and site every hour.

Notify physician for signs of increasing respiratory distress.

Organize care to allow for uninterrupted rest periods.

What is the earliest recognizable clinical manifestation(s) of CF?

Meconium ileus

History of poor intestinal absorption

Foul-smelling, frothy, greasy stools

Recurrent pneumonia and lung infections

What should the nurse teach a child about using an albuterol metered-dose inhaler for

exercise-induced asthma?

Take two puffs every 6 hours around the clock.

Use the inhaler only when the child is short of breath.

Use the inhaler 30 minutes before exercise.

Take one to two puffs every morning upon awakening.

The infant with bronchopulmonary dysplasia (BPD) who has RSV bronchiolitis is a

candidate for which treatment?

Pancreatic enzymes

Cool humidified oxygen

Erythromycin intravenously

Intermittent positive pressure ventilation

Pancreatic enzymes

Cool humidified oxygen

Erythromycin intravenously

Intermittent positive pressure ventilation

Which statement, if made by parents of a child with cystic fibrosis, indicates that they

understood the nurses teaching on pancreatic enzyme replacement?

Enzymes will improve my childs breathing.

I should give the enzymes 1 hour after meals.

Enzymes should be given with meals and snacks.

The enzymes are stopped if my child begins wheezing.

Which vitamin supplements are necessary for children with cystic fibrosis?

Vitamin C and calcium

Vitamin B6 and B12

Magnesium

Vitamins A, D, E, and K

Chapter 41 Nursing Care of the Child With an Alteration in Perfusion/Cardiovascular Disorder

MULTIPLE CHOICE

Which postoperative intervention should be questioned for a child after a cardiac

catheterization?

Continue intravenous (IV) fluids until the infant is tolerating oral fluids.

Check the dressing for bleeding.

Assess peripheral circulation on the affected extremity.

Keep the affected leg flexed and elevated.

Which information should be included in the nurses discharge instructions for a child who

underwent a cardiac catheterization earlier in the day?

Pressure dressing is changed daily for the first week.

The child may soak in the tub beginning tomorrow.

Contact sports can be resumed in 2 days.

The child can return to school on the third day after the procedure.

The nurse is admitting a child to the hospital for a cardiac workup. What is the first step in a

cardiac assessment?

Percussion

Palpation

Auscultation

History and inspection

In which situation is there a risk that a newborn infant will have a congenital heart defect

(CHD)?

Trisomy 21 detected on amniocentesis

Family history of myocardial infarction

Father has type 1 diabetes mellitus

Older sibling born with Turner syndrome

Before giving a dose of digoxin (Lanoxin), the nurse checked an infants apical heart rate and it

was 114 bpm. What should the nurse do next?

Administer the dose as ordered.

Hold the medication until the next dose.

c.Wait and recheck the apical heart rate in 30 minutes.

Notify the physician about the infants heart rate.

Administer the dose as ordered.

Hold the medication until the next dose.

Wait and recheck the apical heart rate in 30 minutes.

Notify the physician about the infants heart rate.

What intervention should be included in the plan of care for an infant with the nursing

diagnosis of Excess Fluid Volume related to congestive heart failure?

Weigh the infant every day on the same scale at the same time.

Notify the physician when weight gain exceeds more than 20 g/day.

Put the infant in a car seat to minimize movement.

Administer digoxin (Lanoxin) as ordered by the physician.

The nurse assessing a premature newborn infant auscultates a continuous machinery-like

murmur. This finding is associated with which congenital heart defect?

Pulmonary stenosis

Patent ductus arteriosus

Ventricular septal defect

Coarctation of the aorta

What is an expected assessment finding in a child with coarctation of the aorta?

Orthostatic hypotension

Systolic hypertension in the lower extremities

Blood pressure higher on the left side of the body

Disparity in blood pressure between the upper and lower extremities

A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this childs

laboratory values, the nurse is not surprised to notice which abnormality?

Polycythemia

Infection

Dehydration

Anemia

Which statement made by a parent indicates understanding of restrictions for a child after

cardiac surgery?

My child needs to get extra rest for a few weeks.

My son is really looking forward to riding his bike next week.

Im so glad we can attend religious services as a family this coming Sunday.

I am going to keep my child out of daycare for 6 weeks.

A child had an aortic stenosis defect surgically repaired 6 months ago. Which antibiotic

prophylaxis is indicated for an upcoming tonsillectomy?

No antibiotic prophylaxis is necessary.

Amoxicillin is taken orally 1 hour before the procedure.

Oral penicillin is given for 7 to 10 days before the procedure.

Parenteral antibiotics are administered for 5 to 7 days after the procedure.

The nurse discovers a heart murmur in an infant 1 hour after birth. She is aware that fetal

shunts are closed in the neonate at what point?

When the umbilical cord is cut

Within several days of birth

Within a month after birth

By the end of the first year of life

Within several days of birth

Within a month after birth

By the end of the first year of life

When assessing a child for possible congenital heart defects (CHDs), where should the nurse

measure blood pressure?

The right arm

The left arm

All four extremities

Both arms while the child is crying

What is the nurses first action when planning to teach the parents of an infant with a CHD?

Assess the parents anxiety level and readiness to learn.

Gather literature for the parents.

Secure a quiet place for teaching.

Discuss the plan with the nursing team.

Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is

important that the nurse understands this condition. Which statement best describes patent ductus

arteriosus?

Patent ductus arteriosus involves a defect that results in a right-to-left shunting

of blood in the heart.

Patent ductus arteriosus involves a defect in which the fetal shunt between the

aorta and the pulmonary artery fails to close.

Patent ductus arteriosus is a stenotic lesion that must be surgically corrected at

birth.

Patent ductus arteriosus causes an abnormal opening between the four chambers

of the heart.

For what reason might a newborn infant with a cardiac defect, such as coarctation of the

aorta, that results in a right-to-left shunt receive prostaglandin E1?

To decrease inflammation

To control pain

To decrease respirations

To improve oxygenation

Which CHD results in increased pulmonary blood flow?

Ventricular septal defect

Coarctation of the aorta

Tetralogy of Fallot

Pulmonary stenosis

Which statement suggests that a parent understands how to correctly administer digoxin?

I measure the amount I am supposed to give with a teaspoon.

I put the medicine in the babys bottle.

When she spits up right after I give the medicine, I give her another dose.

I give the medicine at 8 in the morning and evening every day.

What is the appropriate priority nursing action for the infant with a CHD who has an

increased respiratory rate, is sweating, and is not feeding well?

Recheck the infants blood pressure.

Alert the physician.

Withhold oral feeding.

Increase the oxygen rate.

Nursing care for the child in congestive heart failure includes

Counting the number of saturated diapers

Putting the infant in the Trendelenburg position

Removing oxygen while the infant is crying

Organizing care to provide rest periods

Putting the infant in the Trendelenburg position

Removing oxygen while the infant is crying

Organizing care to provide rest periods

Which strategy is appropriate when feeding the infant with congestive heart failure?

Continue the feeding until a sufficient amount of formula is taken.

Limit feeding time to no more than 30 minutes.

Always bottle feed every 4 hours.

Feed larger volumes of concentrated formula less frequently.

A nurse is teaching an adolescent about primary hypertension. Which statement made by the

adolescent indicates an understanding of primary hypertension?

Primary hypertension should be treated with diuretics as soon as it is detected.

Congenital heart defects are the most common cause of primary hypertension.

Primary hypertension may be treated with weight reduction.

Primary hypertension is not affected by exercise.

An adolescent being seen by the nurse practitioner for a sports physical is identified as

having hypertension. On further testing, it is discovered the child has a cardiac abnormality. The

initial treatment of secondary hypertension initially involves

Weight control and diet

Treating the underlying disease

Administration of digoxin

Administration of beta-adrenergic receptor blockers

What should the nurse include in discharge teaching as the highest priority for the child with

a cardiac dysrhythmia?

CPR instructions

Repeating digoxin if the child vomits

Resting if dizziness occurs

Checking the childs pulse after digoxin administration

A nurse is assigned to care for an infant with an unrepaired tetralogy of Fallot. What should

the nurse do first when the baby is crying and becomes severely cyanotic?

Place the infant in a knee-chest position.

Administer oxygen.

Administer morphine sulfate.

Calm the infant.

The nurse caring for a child diagnosed with acute rheumatic fever should assess the child for

Sore throat

Elevated blood pressure

Desquamation of the fingers and toes

Tender, warm, inflamed joints

Sore throat

Elevated blood pressure

Desquamation of the fingers and toes

Tender, warm, inflamed joints

Chapter 42 Nursing Care of the Child With Alteration in Bowel Elimination/Gastrointestinal Disorder

MULTIPLE CHOICE

What is the best response by the nurse to a mother asking about the cause of her infants

bilateral cleft lip?

Did you use alcohol during your pregnancy?

Do you know of anyone in your family or the babys fathers family who was

born with cleft lip or palate problems?

This defect is associated with intrauterine infection during the second trimester.

The prevalent of cleft lip is higher in Caucasians

Do you know of anyone in your family or the babys fathers family who was

born with cleft lip or palate problems?

This defect is associated with intrauterine infection during the second trimester.

The prevalent of cleft lip is higher in Caucasians

The postoperative care plan for an infant with surgical repair of a cleft lip includes

A clear liquid diet for 72 hours

Nasogastric feedings until the sutures are removed

Elbow restraints to keep the infants fingers away from the mouth

Rinsing the mouth after every feeding

The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF). Nursing

care should include

Elevating the head but give nothing by mouth

Elevating the head for feedings

Feeding glucose water only

A nurse is teaching a group of parents about TEF. Which statement made by the nurse is

accurate about TEF?

This defect results from an embryonal failure of the foregut to differentiate into

the trachea and esophagus.

It is a fistula between the esophagus and stomach that results in the oral intake

being refluxed and aspirated.

An extra connection between the esophagus and trachea develops because of

genetic abnormalities.

The defect occurs in the second trimester of pregnancy.

What maternal assessment is related to an infants diagnosis of TEF?

Maternal age more than 40 years

First term pregnancy for the mother

Maternal history of polyhydramnios

Complicated pregnancy

What clinical manifestation should a nurse be alert for when suspecting a diagnosis of

esophageal atresia?

a.A

radiograph in the prenatal period indicates abnormal development.

It is visually identified at the time of delivery.

A nasogastric tube fails to pass at birth.

A radiograph in the prenatal period indicates abnormal development.

It is visually identified at the time of delivery.

A nasogastric tube fails to pass at birth.

The infant has a low birth weight.

What is the most important information to be included in the discharge planning for an infant

with gastroesophageal reflux?

Teach parents to position the infant on the left side.

Reinforce the parents knowledge of the infants developmental needs.

Teach the parents how to do infant cardiopulmonary resuscitation (CPR).

Have the parents keep an accurate record of intake and output.

Teach the parents how to do infant cardiopulmonary resuscitation (CPR).

Have the parents keep an accurate record of intake and output.

What information should the nurse include when teaching the parents of a 5-week-old infant

about pyloromyotomy?

The infant will be in the hospital for a week.

The surgical procedure is routine and no big deal.

The prognosis for complete correction with surgery is good.

They will need to ask the physician about home care nursing.

A nurse has admitted a child to the hospital with a diagnosis of rule out peptic ulcer disease.

Which test will the nurse expect to be ordered to confirm the diagnosis of a peptic ulcer?

A dietary history

A positive Hematest result on a stool sample

A fiberoptic upper endoscopy

An abdominal ultrasound

What should the nurse teach a school-age child and his parents about the management of

ulcer disease?

Eat a bland, low-fiber diet in small, frequent meals.

Eat three balanced meals a day with no snacking between meals.

The child needs to eat alone to avoid stress.

Do not give antacids 1 hour before or after antiulcer medications.

What is the major focus of the therapeutic management for a child with lactose intolerance?

Compliance with the medication regimen.

Providing emotional support to family members.

Teaching dietary modifications.

Administration of daily normal saline enemas.

The child with lactose intolerance is most at risk for which electrolyte imbalance?

Hyperkalemia

Hypoglycemia

Hyperglycemia

Hypocalcemia

Hyperkalemia

Hypoglycemia

Hyperglycemia

Hypocalcemia

What food choice by the parent of a 2-year-old child with celiac disease indicates a need for

further teaching?

Oatmeal

Rice cake

Corn muffin

d.Meat patty

Rice cake

Corn muffin

Meat patty

Which assessment finding should the nurse expect in an infant with Hirschsprung disease?

Currant jelly stools

Constipation with passage of foul-smelling, ribbon-like stools

Foul-smelling, fatty stools

Diarrhea

What is an expected outcome for the parents of a child with encopresis?

The parents will give the child an enema daily for 3 to 4 months.

The family will develop a plan to achieve control over incontinence.

The parents will have the child launder soiled clothes.

The parents will supply the child with a low-fiber diet.

Which intervention should be included in the nurses plan of care for a 7-year-old child with

encopresis who has cleared the initial impaction?

Have the child sit on the toilet for 30 minutes when he gets up in the morning

and at bedtime.

Increase sugar in the childs diet to promote bowel elimination.

Use a Fleets enema daily.

Give the child a choice of beverage to mix with a laxative.

The nurse is teaching the parents of a child who has been diagnosed with irritable bowel

syndrome about the pathophysiology associated with the symptoms their child is experiencing.

Which response indicates to the nurse that her teaching has been effective?

My child has an absence of ganglion cells in the rectum causing alternating

diarrhea and constipation.

The cause of my childs diarrhea and constipation is disorganized intestinal

contractility.

My child has an intestinal obstruction; thats why he has abdominal pain.

My child has an intolerance to gluten, and this causes him to have abdominal

pain.

What is an expected outcome for the child with irritable bowel disease?

Decreasing symptoms

Adherence to a low-fiber diet

Increasing milk products in the diet

Adapting the lifestyle to the lifelong problems

An infant is born and the nurse notices that the child has herniation of abdominal viscera into

the base of the umbilical cord. What will the nurse document on her or his assessment of this

condition?

Diaphragmatic hernia

Umbilical hernia

Gastroschisis

Omphalocele

What is an appropriate statement for the nurse to make to parents of a child who has had a

barium enema to correct an intussusception?

I will call the physician when the baby passes his first stool.

I am going to dilate the anal sphincter with a gloved finger to help the baby pass

the barium.

I would like you to save all the soiled diapers so I can inspect them.

Add cereal to the babys formula to help him pass the barium.

I will call the physician when the baby passes his first stool.

I am going to dilate the anal sphincter with a gloved finger to help the baby pass

the barium.

I would like you to save all the soiled diapers so I can inspect them.

Add cereal to the babys formula to help him pass the barium.

What is the best response to parents who ask why their infant has a nasogastric tube to

intermittent suction before abdominal surgery for hypertrophic pyloric stenosis?

The nasogastric tube decompresses the abdomen and decreases vomiting.

We can keep a more accurate measure of intake and output with the nasogastric

tube.

The tube is used to decrease postoperative diarrhea.

Believe it or not, the nasogastric tube makes the baby more comfortable after

surgery.

Which description of a stool is characteristic of intussusception?

Ribbon-like stools

Hard stools positive for guaiac

Currant jelly stools

Loose, foul-smelling stools

What is a priority concern for a 14-year-old child with inflammatory bowel disease?

Compliance with antidiarrheal medication therapy

Long-term complications

Dealing with the embarrassment and stress of diarrhea

Home schooling

Which statement about Crohn disease is the most accurate?

The signs and symptoms of Crohn disease are usually present at birth.

Signs and symptoms of Crohn disease include abdominal pain, diarrhea, and

often a palpable abdominal mass.

Edema usually accompanies this disease.

Symptoms of Crohn disease usually disappear by late adolescence.

Therapeutic management of the child with acute diarrhea and dehydration usually begins

with

Clear liquids

Adsorbents, such as kaolin and pectin

Oral rehydration solution (ORS)

Antidiarrheal medications such as paregoric

What is the most important action to prevent the spread of gastroenteritis in a daycare

setting?

Administering prophylactic medications to children and staff

b.Frequent handwashing

Having parents bring food from home

Directing the staff to wear gloves at all times

Administering prophylactic medications to children and staff

Frequent handwashing

Having parents bring food from home

Directing the staff to wear gloves at all times

What is an expected outcome for a 1-month-old infant with biliary atresia?

Correction of the defect with the Kasai procedure

Adequate nutrition and age-appropriate growth and development

Adherence to a salt-free diet with vitamin B12 supplementation

Adequate protein intake

Which assessment finding is the most significant to report to the physician for a child with

cirrhosis?

Weight loss

Change in level of consciousness

Skin with pruritus

Black, foul-smelling stools

Which nursing diagnosis has the highest priority for the toddler with celiac disease?

Disturbed Body Image related to chronic constipation

Risk for Disproportionate Growth related to obesity

Excess Fluid Volume related to celiac crisis

Imbalanced Nutrition: Less than Body Requirements related to malabsorption

The nurse notes on assessment that a 1-year-old child is underweight, with abdominal

distention, thin legs and arms, and foul-smelling stools. The nurse suspects failure to thrive is

associated with

Celiac disease

Intussusception

Irritable bowel syndrome

Imperforate anus

The nurse caring for a child with suspected appendicitis should question which order from

the physician?

Keep patient NPO.

Start IV of D5/0.45 normal saline at 60 mL/hr.

Apply K-pad to abdomen prn for pain.

Obtain CBC on admission to nursing unit.

Which order should the nurse question when caring for a 5-year-old child after surgery for

Hirschsprung disease?

Monitor rectal temperature every 4 hours and report an elevation greater than

38.5 C.

Assess stools after surgery.

Keep the child NPO until bowel sounds return.

Maintain IV fluids at ordered rate.

Which parasite causes acute diarrhea?

Shigella organisms

Salmonella organisms

Giardia lamblia

Escherichia coli

Salmonella organisms

Giardia lamblia

Escherichia coli

What goal has the highest priority for a child with malabsorption associated with lactose

intolerance?

The child will experience no abdominal spasms.

The child will not experience constipation associated with malabsorption

syndrome.

The child will not experience diarrhea associated with malabsorption syndrome.

The child will receive adequate nutrition as evidenced by a weight gain of 1 kg/

day.

What should the nurse stress in a teaching plan for the mother of an 11-year-old boy with

ulcerative colitis?

Preventing the spread of illness to others

Nutritional guidance and preventing constipation

Teaching daily use of enemas

Coping with stress and avoiding triggers

An infant with imperforate anus has an anal plasty and temporary colostomy. Which

statement by the infants mother indicates that she understands how to care for the infants

colostomy at home?

I will call the doctor right away if my baby starts vomiting.

Ill call my home health nurse if the colostomy bag needs to be changed.

Ill call the doctor if I notice that the colostomy stoma is pink.

Ill have my mother help me with the care of the colostomy.

Chapter 43 Nursing Care of the Child With Alteration in Urinary Elimination/Genitourinary Disorder

MULTIPLE CHOICE

Which statement by a school-age girl indicates the need for further teaching about the

prevention of urinary tract infections (UTIs)?

I always wear cotton underwear.

I really enjoy taking a bubble bath.

I go to the bathroom every 3 to 4 hours.

I drink four to six glasses of fluid every day.

The nurse assessing a child with acute poststreptococcal glomerulonephritis should be alert for

which finding?

Increased urine output

Hypotension

Tea-colored urine

Weight gain

The mother of a child who was recently diagnosed with acute glomerulonephritis asks the

nurse why the physician keeps talking about casts in the urine. The nurses response is based on

the knowledge that the presence of casts in the urine indicates

Glomerular injury

Glomerular healing

Recent streptococcal infection

Excessive amounts of protein in the urine

Which clinical finding warrants further intervention for the child with acute poststreptococcal

glomerulonephritis?

Weight loss to within 1 lb of the preillness weight

Urine output of 1 mL/kg/hr

A positive antistreptolysin O (ASO) titer

d.Inspiratory crackles

Urine output of 1 mL/kg/hr

A positive antistreptolysin O (ASO) titer

Inspiratory crackles

Which diagnostic finding is present when a child has primary nephrotic syndrome?

Hyperalbuminemia

Positive ASO titer

Leukocytosis

Proteinuria

Which finding indicates that a child receiving prednisone for primary nephrotic syndrome is in

remission?

Urine is negative for casts for 5 days.

Urine is up to a trace for protein for 5 to 7 days.

Urine is positive for glucose for 1 week.

Urine is up to a trace for blood for 1 week.

Which statement by a parent of a child with nephrotic syndrome indicates an understanding of

a no-added-salt diet?

I can give my child sweet pickles.

My child can put ketchup on his hotdog.

I can let my child have potato chips.

I do not put any salt in foods when I am cooking.

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

What is an appropriate intervention for a child with nephrotic syndrome who is edematous?

Teach the child to minimize body movements.

Change the childs position every 2 hours.

Avoid the use of skin lotions.

Bathe every other day.

What should the nurse include in a teaching plan for the parents of a child with vesicoureteral

reflux?

The importance of taking prophylactic antibiotics

Suggestions for how to maintain fluid restrictions

The use of bubble baths as an incentive to increase bath time

The need for the child to hold urine for 6 to 8 hours

Which intervention is appropriate when examining a male infant for cryptorchidism?

Cooling the examiners hands

Taking a rectal temperature

Eliciting the cremasteric reflex

Warming the room

Cooling the examiners hands

Taking a rectal temperature

Eliciting the cremasteric reflex

Warming the room

Parents ask the nurse when should our childs hypospadias be corrected? The nurse responds

based upon the knowledge that correction of hypospadias should be accomplished by the time

the child is

1 month of age

6 to 12 months of age

School age

d.Sexually mature

6 to 12 months of age

School age

Sexually mature

You are the nurse caring for a 4-year-old child who has developed acute renal failure as a

result of hemolytic-uremic syndrome (HUS). Which bacterial infection was most likely the cause

of HUS?

Pseudomonas aeruginosa

Escherichia coli

Streptococcus pneumoniae

Staphylococcus aureus

Which dietary modification is appropriate for a child with chronic renal failure?

Decreased protein

Decreased fat

Increased potassium

Increased phosphorus

Which condition is characterized by a history of bloody diarrhea, fever, abdominal pain, and

low hemoglobin and platelet counts?

Acute viral gastroenteritis

Acute glomerulonephritis

Hemolytic-uremic syndrome

Acute nephrotic syndrome

A child with secondary enuresis who complains of dysuria or urgency should be evaluated

for which condition?

Hypocalciuria

Nephrotic syndrome

Glomerulonephritis

UTI

A nurse is teaching a class on acute renal failure. The nurse relates that acute renal failure as

a result of hemolytic-uremic syndrome (HUS) is classified as

Intrarenal

b.Prerenal

Postrenal

Chronic

Intrarenal

Prerenal

Postrenal

Chronic

A true statement describing the differences in the pediatric genitourinary system compared

with the adult genitourinary system is that

The young infants kidneys can more effectively concentrate urine than an adults

kidneys.

After 6 years of age, kidney function is nearly like that of an adult.

c.Unlike adults, most children do not regain normal kidney function after acute

renal failure.

Young children have shorter urethras, which can predispose them to UTIs.

The young infants kidneys can more effectively concentrate urine than an adults

kidneys.

After 6 years of age, kidney function is nearly like that of an adult.

Unlike adults, most children do not regain normal kidney function after acute

renal failure.

Young children have shorter urethras, which can predispose them to UTIs.

Which factor predisposes the urinary tract to infection?

Increased fluid intake

Short urethra in young girls

Prostatic secretions in males

Frequent emptying of the bladder

Hypospadias refers to

Absence of a urethral opening

Penis shorter than usual for age

Urethral opening along dorsal surface of penis

Urethral opening along ventral surface of penis

The narrowing of preputial opening of foreskin is called

Chordee

Phimosis

Epispadias

Hypospadias

The nurse closely monitors the temperature of a child with nephrotic syndrome. The purpose

of this is to detect an early sign of which possible complication?

Infection

Hypertension

Encephalopathy

Edema

A child is admitted with acute glomerulonephritis. The nurse expects the urinalysis during

this acute phase to show

Bacteriuria and hematuria

Hematuria and proteinuria

Bacteriuria and increased specific gravity

Proteinuria and decreased specific gravity

Hematuria and proteinuria

Bacteriuria and increased specific gravity

Proteinuria and decreased specific gravity

The most appropriate nursing diagnosis for the child with acute glomerulonephritis is

Risk for Injury related to malignant process and treatment

Deficient Fluid Volume related to excessive losses

Risk for Imbalanced Fluid Volume related to a decrease in plasma filtration

Excess Fluid Volume related to fluid accumulation in tissues and third spaces

Chapter 44 Nursing Care of Child With Alteration in Mobility/Neuromuscular

Musculoskeletal Disorder

MULTIPLE CHOICE

Which statement is accurate concerning a childs musculoskeletal system and how it may be

different from an adults?

Growth occurs in children as a result of an increase in the number of muscle

fibers.

Infants are at greater risk for fractures because their epiphyseal plates are not

fused.

Because soft tissues are resilient in children, dislocations and sprains are less

common than in adults.

Their bones have less blood flow.

When infants are seen for fractures, which nursing intervention is a priority?

No intervention is necessary. It is not uncommon for infants to fracture bones.

Assess the familys safety practices. Fractures in infants usually result from falls.

Assess for child abuse. Fractures in infants are often nonaccidental.

Assess for genetic factors.

Which nursing intervention is appropriate to assess for neurovascular competency in a child

who fell off the monkey bars at school and hurt his arm?

The degree of motion and ability to position the extremity

The length, diameter, and shape of the extremity

The amount of swelling noted in the extremity and pain intensity

The skin color, temperature, movement, sensation, and capillary refill of the

extremity

A mother whose 7-year-old child has been placed in a cast for a fractured right arm reports

that he will not stop crying even after taking acetaminophen with codeine. He also will not

straighten the fingers on his right arm. The nurse tells the mother to

Take him to the emergency department.

Put ice on the injury.

Avoid letting him get so tired.

Wait another hour; if he is still crying, call back.

A 4-year-old child with a long leg cast complains of fire in his cast. The nurse should

Notify the physician on his next rounds.

Note the complaint in the nurses notes.

Notify the physician immediately.

Report the complaint to the next nurse on duty.

When a child with a musculoskeletal injury on the foot is assessed, what is most indicative of

a fracture?

Increased swelling after the injury is iced

The presence of localized tenderness distal to the site

The presence of an elevated temperature for 24 hours

The inability of the child to bear weight

Increased swelling after the injury is iced

The presence of localized tenderness distal to the site

The presence of an elevated temperature for 24 hours

The inability of the child to bear weight

A child with osteomyelitis asks the nurse, What is a sed rate? What is the best response for the

nurse?

It tells us how you are responding to the treatment.

b.It tells us what type of antibiotic you need.

It tells us whether we need to immobilize your extremity.

It tells us how your nerves and muscles are doing.

It tells us how you are responding to the treatment.

It tells us what type of antibiotic you need.

It tells us whether we need to immobilize your extremity.

It tells us how your nerves and muscles are doing.

Which interaction is part of the discharge plan for a school-age child with osteomyelitis who is

receiving home antibiotic therapy?

Instructions for a low-calorie diet

Arrange for tutoring and school work

Instructions for a high-fat, low-protein diet

Instructions for the parent to return the child to team sports immediately

During a 14-year-olds physical examination, the nurse identifies that he plays soccer and

football and is complaining of knee pain when he rises from a squatting position, and difficulty

with weight bearing. The nurse should suspect

Legg-Calv-Perthes disease

Osteomyelitis

Duchenne muscular dystrophy

Osgood-Schlatter disease

A child is upset because, when the cast is removed from her leg, the skin surface is caked

with desquamated skin and sebaceous secretions. What should the nurse suggest to remove this

material?

Wash the area with warm water and soap.

Vigorously scrub leg.

Apply powder to absorb material.

Carefully pick material off leg.

Which factor is important to include in the teaching plan for parents of a child with Legg-

Calv-Perthes disease?

It is an acute illness lasting 1 to 2 weeks.

It affects primarily adolescents.

There is a disturbance in the blood supply to the femoral epiphysis.

It is caused by a virus.

What is the major concern guiding treatment for the child with Legg-Calv-Perthes disease?

Avoid permanent deformity.

Minimize pain.

Maintain normal activities.

Encourage new hobbies.

A neonate is born with mild clubfeet. When the parents ask the nurse how this will be

corrected, the nurse should explain that

Traction is tried first.

Surgical intervention is needed.

Frequent, serial casting is tried first.

Children outgrow this condition when they learn to walk.

Discharge planning for the child with juvenile arthritis includes the need for

Routine ophthalmologic examinations to assess for visual problems

A low-calorie diet to decrease or control weight in the less mobile child

Avoiding the use of aspirin to decrease gastric irritation

Immobilizing the painful joints, which is the result of the inflammatory process

During painful episodes of juvenile arthritis, a plan of care should include what nursing

intervention?

A weight-control diet to decrease stress on the joints

Proper positioning of the affected joints to prevent musculoskeletal

complications

Complete bed rest to decrease stress to joints

High-resistance exercises to maintain muscular tone in the affected joints

When assessing a child for an upper extremity fracture, the nurse should know that these

fractures most often result from

Automobile accidents

Falls

c.Physical abuse

Sports injuries

Falls

Physical abuse

Sports injuries

In caring for a child with a compound fracture, the nurse should carefully assess for

Infection

Osteoarthritis

Epiphyseal disruption

Periosteum thickening

A nurse is teaching parents the difference between pediatric fractures and adult fractures.

Which observation is true about pediatric fractures?

They seldom are complete breaks.

They are often compound fractures.

They are often at the epiphyseal plate.

They are often the result of decreased mobility of the bones.

ANS: A

Patient and parent education for the child who has a synthetic cast should include

Applying a heating pad to the cast if the child has swelling in the affected

extremity

Wrapping the outer surface of the cast with an Ace bandage

Splitting the cast if the child complains of numbness or pain

Covering the cast with plastic and waterproof tape to keep it dry while bathing

or showering

A 6-year-old patient who has been placed in skeletal traction has pain, edema, and fever. The

nurse should suspect

Meningitis

Crepitus

Osteomyelitis

Osteochondrosis

A boy who has fractured his forearm is unable to extend his fingers. The nurse knows that

this

Is normal following this type of injury

b.May indicate compartmental syndrome

May indicate fat embolism

May indicate damage to the epiphyseal plate

Is normal following this type of injury

May indicate compartmental syndrome

May indicate fat embolism

May indicate damage to the epiphyseal plate

Which term is used to describe an abnormally increased convex angulation in the curvature

of the thoracic spine?

Scoliosis

Ankylosis

c.Lordosis

Kyphosis

Scoliosis

Ankylosis

Lordosis

Kyphosis

When assessing the child with osteogenesis imperfecta, the nurse should expect to observe

Discolored teeth

Below-normal intelligence

Increased muscle tone

Above-average stature

Chapter 45 Nursing Care of the Child With an Alteration in Tissue Integrity/Integumentary Disorder

MULTIPLE CHOICE

What should be included in teaching a parent about the management of small red macules and

vesicles that become pustules around the childs mouth and cheek?

Keep the child home from school for 24 hours after initiation of antibiotic

treatment.

Clean the rash vigorously with Betadine three times a day.

Notify the physician for any itching.

Keep the child home from school until the lesions are healed.

When taking a history on a child with a possible diagnosis of cellulitis, what should be the

priority nursing assessment to help establish a diagnosis?

Any pain the child is experiencing

Enlarged, mobile, and nontender lymph nodes

Childs urinalysis results

Recent infections or signs of infection

Which statement made by a parent indicates an understanding about the management of a

child with cellulitis?

I am supposed to continue the antibiotic until the redness and swelling

disappear.

I have been putting ice on my sons arm to relieve the swelling.

I should call the doctor if the redness disappears.

I have been putting a warm soak on my sons arm every 4 hours.

What should the parents of an infant with thrush (oral candidiasis) be taught about medication

administration?

Give nystatin suspension with a syringe without a needle.

Apply nystatin cream to the affected area twice a day.

Give nystatin before the infant is fed.

Swab nystatin suspension onto the oral mucous membranes after feedings.

With what beverage should the parents of a child with ringworm be taught to give

griseofulvin?

Water

A carbonated drink

Milk

Fruit juice

Which nursing assessment is applicable to the care of a child with herpetic gingivostomatitis?

Comparison of range of motion for the upper and lower extremities

Urine output, mucous membranes, and skin turgor

c.Growth pattern since birth

Bowel elimination pattern

Comparison of range of motion for the upper and lower extremities

Urine output, mucous membranes, and skin turgor

Growth pattern since birth

Bowel elimination pattern

Parents of a child with lice infestation should be instructed carefully in the use of antilice

products because of which potential side effect?

Nephrotoxicity

Neurotoxicity

Ototoxicity

Bone marrow depression

Ototoxicity

Bone marrow depression

When assessing the child with atopic dermatitis, the nurse should ask the parents about a

history of

Asthma

Nephrosis

Lower respiratory tract infections

Neurotoxicity

What should the nurse teach an adolescent who is taking tretinoin (Retin-A) to treat acne?

The medication should be taken with meals.

Apply sunscreen before going outdoors.

Wash with benzoyl peroxide before application.

The effect of the medication should be evident within 1 week.

When changing an infants diaper, the nurse notices small bright red papules with satellite

lesions on the perineum, anterior thigh, and lower abdomen. This rash is characteristic of

Primary candidiasis

Irritant contact dermatitis

Intertrigo

Seborrheic dermatitis

The depth of a burn injury may be classified as

Localized or systemic

Superficial, superficial partial thickness, deep partial thickness, or full thickness

Electrical, chemical, or thermal

Minor, moderate, or major

What best describes a full-thickness (third-degree) burn?

Erythema and pain

Skin showing erythema followed by blister formation

Destruction of all layers of skin evident with extension into subcutaneous tissue

Destruction injury involving underlying structures such as muscle, fascia, and

Erythema and pain

Skin showing erythema followed by blister formation

Destruction of all layers of skin evident with extension into subcutaneous tissue

Destruction injury involving underlying structures such as muscle, fascia, and

bone

What procedure is contraindicated in the care of a child with a minor partial-thickness burn

injury wound?

Cleaning the affected area with mild soap and water

Applying antimicrobial ointment to the burn wound

Changing dressings daily

d.Leaving all loose tissue or skin intact

Applying antimicrobial ointment to the burn wound

Changing dressings daily

Leaving all loose tissue or skin intact

The process of burn shock continues until what physiologic mechanism occurs?

Heart rate returns to normal.

Airway swelling decreases.

Body temperature regulation returns to normal.

Capillaries regain their seal.

To assess the child with severe burns for adequate perfusion, the nurse monitors

Distal pulses

Skin turgor

Urine output

Mucous membranes

What nursing assessment and care holds the highest priority in the initial care of a child with

a major burn injury?

Establishing and maintaining the childs airway

Establishing and maintaining intravenous access

Inserting a catheter to monitor hourly urine output

Inserting a nasogastric tube into the stomach to supply adequate nutrition

An important nursing consideration when caring for a child with impetigo contagiosa is to

Apply topical corticosteroids to decrease inflammation.

Carefully remove dressings so as not to dislodge undermined skin, crusts, and

debris.

Carefully wash hands and maintain cleanliness when caring for an infected

child.

Examine child under a Wood lamp for possible spread of lesions.

Impetigo ordinarily results in

No scarring

Pigmented spots

Slightly depressed scars

Atrophic white scars

The pediatric nurse understands that cellulitis is most often caused by

Herpes zoster

Candida albicans

Human papillomavirus

Streptococcus or Staphylococcus organisms

The skin condition commonly known as warts is the result of an infection by which

organism?

Bacteria

Fungus

Parasite

Virus

The primary treatment for warts is

Vaccination

Local destruction

Corticosteroids

Specific antibiotic therapy

Treatment for herpes simplex virus (types 1 or 2) includes

Corticosteroids

Oral griseofulvin

Oral antiviral agent

Topical and/or systemic antibiotic

Ringworm, frequently found in schoolchildren, is caused by a(n)

Virus

Fungus

Allergic reaction

Bacterial infection

Fungus

Allergic reaction

Bacterial infection

The primary clinical manifestation of scabies is

Edema

Redness

Pruritus

Maceration

The management of a child who has just been stung by a bee or wasp should include the

application of

Cool compresses

Warm compresses

Antibiotic cream

Corticosteroid cream

Chapter 46 Nursing Care of Child With Alteration Cellular Regulation/Hematologic Neoplastic Disorder

MULTIPLE CHOICE

What is the best response to a parent who asks the nurse whether her 5-month-old infant can

have cows milk?

You need to wait until she is 8 months old and eating solids well.

Yes, if you think that she will eat enough meat to get the iron she needs.

Infants younger than 12 months need iron-rich formula to get the iron they need.

Try it and see how she tolerates it.

MSC: Client Needs: Health Promotion and Maintenance

An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to

reveal an infant who is

Lethargic, pale, and irritable

Thin, energetic, and sleeps little

Anorexic, vomiting, and has watery stools

Flushed, fussy, and tired

What action is not appropriate for a 14-month-old child with iron deficiency anemia?

Decreasing the infants daily milk intake to 24 oz or less

Giving oral iron supplements between meals with orange juice

Including apricots, dark-green leafy vegetables, and egg yolk in the infants diet

Allowing the infant to drink the iron supplement from a small medicine cup

An accurate description of anemia is

Increased blood viscosity

Depressed hematopoietic system

Presence of abnormal hemoglobin

Decreased oxygen-carrying capacity of blood

What is true about the genetic transmission of sickle cell disease?

Both parents must carry the sickle cell trait.

b.Both parents must have sickle cell disease.

One parent must have the sickle cell trait.

Sickle cell disease has no known pattern of inheritance.

Both parents must carry the sickle cell trait.

Both parents must have sickle cell disease.

One parent must have the sickle cell trait.

Sickle cell disease has no known pattern of inheritance.

A condition in which the normal adult hemoglobin is partly or completely replaced by

abnormal hemoglobin is known as

Aplastic anemia

Sickle cell anemia

Thalassemia major

Iron-deficiency anemia

What are the nursing priorities for a child with sickle cell disease in vaso-occlusive crisis?

Administration of antibiotics and nebulizer treatments

Hydration and pain management

Blood transfusions and an increased calorie diet

School work and diversion

What describes the pathologic changes of sickle cell anemia?

Sickle-shaped cells carry excess oxygen.

Sickle-shaped cells decrease blood viscosity.

Increased red blood cell destruction occurs.

Decreased red blood cell destruction occurs.

Which clinical manifestation should the nurse expect when a child with sickle cell anemia

experiences an acute vaso-occlusive crisis?

Circulatory collapse

Cardiomegaly, systolic murmurs

Hepatomegaly, intrahepatic cholestasis

Painful swelling of hands and feet; painful joints

What should the discharge plan for a school-age child with sickle cell disease include?

Restricting the childs participation in outside activities

Administering aspirin for pain or fever

Limiting the childs interaction with peers

Administering penicillin daily as ordered

How should the nurse respond when asked by the mother of a child with beta-thalassemia

why the child is receiving deferoxamine?

To improve the anemia.

To decrease liver and spleen swelling.

To eliminate excessive iron being stored in the organs.

To prepare your child for a bone marrow transplant.

To improve the anemia.

To decrease liver and spleen swelling.

To eliminate excessive iron being stored in the organs.

To prepare your child for a bone marrow transplant.

Which statement best describes beta-thalassemia major (Cooley anemia)?

All formed elements of the blood are depressed.

Inadequate numbers of red blood cells are present.

Increased incidence occurs in families of Mediterranean extraction.

Increased incidence occurs in persons of West African descent.

Increased incidence occurs in families of Mediterranean extraction.

Increased incidence occurs in persons of West African descent.

What is the priority nursing intervention for a child hospitalized with hemarthrosis resulting

from hemophilia?

Immobilization and elevation of the affected joint

Administration of acetaminophen for pain relief

Assessment of the childs response to hospitalization

Assessment of the impact of hospitalization on the family system

What is descriptive of most cases of hemophilia?

Autosomal dominant disorder causing deficiency is a factor involved in the

blood-clotting reaction

X-linked recessive inherited disorder causing deficiency of platelets and

prolonged bleeding

X-linked recessive inherited disorder in which a blood-clotting factor is

deficient

Y-linked recessive inherited disorder in which the red blood cells become moon

shaped

The mother of a child with hemophilia asks the nurse how long her child will need to be

treated for hemophilia. What is the best response to this question?

Hemophilia is a lifelong blood disorder.

There is a 25% chance that your child will have spontaneous remission and

treatment will no longer be necessary.

Treatment is indicated until after your child has progressed through the toddler

years.

It is unlikely that your child will need to be treated for his hemophilia because

your first child does not have the disease.

In teaching family members about their childs von Willebrand disease, what is the priority

outcome for the child that the nurse should discuss?

Prevention of injury

Maintaining adequate hydration

Compliance with chronic transfusion therapy

Prevention of respiratory infections

A child who has been in good health has a platelet count of 45,000/mm3, petechiae, and

excessive bruising that covers the body. The nurse is aware that these signs are clinical

manifestations of

Erythroblastopenia

von Willebrand disease

Hemophilia

Immune thrombocytopenic purpura (ITP)

What is the priority in the discharge plan for a child with immune thrombocytopenic purpura

(ITP)?

Teaching the parents to report excessive fatigue to the physician

Monitoring the childs hemoglobin level every 2 weeks

Providing a diet that contains iron-rich foods

Establishing a safe, age-appropriate home environment

Chapter 47 Nursing Care of the Child With an Alteration in Immunity or Immunologic Disorder

MULTIPLE CHOICE

A nurse in a well-child clinic is teaching parents about their childs immune system. Which

statement by the nurse is correct?

The immune system distinguishes and actively protects the bodys own cells

from foreign substances.

The immune system is fully developed by 1 year of age.

c.The immune system protects the child against communicable diseases in the

first 6 years of life.

The immune system responds to an offending agent by producing antigens.

The immune system distinguishes and actively protects the bodys own cells

from foreign substances.

The immune system is fully developed by 1 year of age.

The immune system protects the child against communicable diseases in the

first 6 years of life.

The immune system responds to an offending agent by producing antigens.

A nurse is teaching parents about the importance of immunizations for infants because of

immaturity of the immune system. The parents demonstrate that they understand the teaching if

they make which statement?

The spleen reaches full size by 1 year of age.

IgM, IgE, and IgD levels are high at birth.

IgG levels in the newborn infant are low at birth.

Absolute lymphocyte counts reach a peak during the first year.

IgM, IgE, and IgD levels are high at birth.

IgG levels in the newborn infant are low at birth.

Absolute lymphocyte counts reach a peak during the first year.

Which organs and tissues control the two types of specific immune functions?

The spleen and mucous membranes

Upper and lower intestinal lymphoid tissue

The skin and lymph nodes

The thymus and bone marrow

Which statement is true regarding how infants acquire immunity?

The infant acquires humoral and cell-mediated immunity in response to

infections and immunizations.

The infant acquires maternal antibodies that ensure immunity up to 12 months

age.

Active immunity is acquired from the mother and lasts 6 to 7 months.

Passive immunity develops in response to immunizations.

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

What is the most common mode of transmission of human immunodeficiency virus (HIV) in

the pediatric population?

Perinatal transmission

Sexual abuse

Blood transfusions

Poor handwashing

The Center for Disease Control (CDC, 2009) recommendation for immunizing infants who are

HIV positive is

Follow the routine immunization schedule.

Routine immunizations are administered; assess CD4+ counts before

administering the MMR and varicella vaccinations.

Do not give immunizations because of the infants altered immune status.

Eliminate the pertussis vaccination because of the risk of convulsions.

Which suggestion is appropriate to teach a mother who has a preschool child who refuses to

take the medications for HIV infection?

Mix medications with chocolate syrup or follow with chocolate candy.

Mix the medications with milk or an essential food.

Skip the dose of medication if the child protests too much.

Mix the medication in a syringe, hold the child down firmly, and administer the

medication.

What is the primary nursing concern for a hospitalized child with HIV infection?

Maintaining growth and development

Eating foods that the family brings to the child

Consideration of parental limitations and weaknesses

Resting for 2 to 3 hours twice a day

Maintaining growth and development

Eating foods that the family brings to the child

Consideration of parental limitations and weaknesses

Resting for 2 to 3 hours twice a day

What should the nurse include in a teaching plan for the mother of a toddler who will be

taking prednisone for several months?

The medication should be taken between meals.

b.The medication needs to be discontinued because of the risks associated with

long-term usage.

The medication should not be stopped abruptly.

The medication may lower blood glucose, so the mother needs to observe for

signs of hypoglycemia.

The medication should be taken between meals.

The medication needs to be discontinued because of the risks associated with

long-term usage.

The medication should not be stopped abruptly.

The medication may lower blood glucose, so the mother needs to observe for

signs of hypoglycemia.

Children receiving long-term systemic corticosteroid therapy are most at risk for

Hypotension

Dilation of blood vessels in the cheeks

Growth delays

Decreased appetite and weight loss

Dilation of blood vessels in the cheeks

Growth delays

Decreased appetite and weight loss

Which statement by a mother about antiretroviral agents for the management for her 5-yearold

child with acquired immunodeficiency syndrome (AIDS) indicates that she has a good

understanding?

When my childs pain increases, I double the recommended dosage of

antiretroviral medication.

Addiction is a risk, so I only use the medication as ordered.

Doses of the antiretroviral medication are selected on the basis of my childs age

and growth.

By the time my child is an adolescent she will not need her antiretroviral

medications any longer.

Which intervention is appropriate for a child receiving high doses of steroids?

Limit activity and receive home schooling.

Decrease the amount of potassium in the diet.

Substitute a killed virus vaccine for live virus vaccines.

Monitor for seizure activity.

The nurse observes a red butterfly-shaped rash that spreads across the childs cheeks and

nose. This assessment finding is characteristic of which condition?

Systemic lupus erythematosus (SLE)

Rheumatic fever

Kawasaki disease

Anaphylactic reaction

What is the primary nursing concern for a child having an anaphylactic reaction?

Identifying the offending allergen

Ineffective breathing pattern

Increased cardiac output

Positioning to facilitate comfort

What is the drug of choice the nurse should administer in the acute treatment of anaphylaxis?

Diphenhydramine

Histamine inhibitor (cimetidine)

Epinephrine

Albuterol

What is caused by a virus that primarily infects a specific subset of T lymphocytes, the CD4+

T cells?

Wiskott-Aldrich syndrome

Idiopathic thrombocytopenic purpura

Acquired immunodeficiency syndrome (AIDS)

Severe combined immunodeficiency disease

Chapter 48 Nursing Care of the Child With an Alteration in Metabolism/Endocrine Disorder

MULTIPLE CHOICE

New parents ask the nurse, Why is it necessary for our baby to have the newborn blood test?

The nurse explains that the priority outcome of mandatory newborn screening for inborn errors

of metabolism is

Appropriate community referral for affected infants

Parental education about raising a special needs child

Early identification of serious genetically transmitted metabolic diseases

Early identification of electrolyte imbalances

Parental education about raising a special needs child

Early identification of serious genetically transmitted metabolic diseases

Early identification of electrolyte imbalances

What is the priority nursing goal for a 14-year-old with Graves disease?

Relieving constipation

Allowing the adolescent to make decisions about whether or not to take

medication

Verbalizing the importance of adherence to the medication regimen

What information provided by the nurse would be helpful to a 15-year-old adolescent taking

methimazole three times a day?

Pill dispensers and alarms on her watch can remind her to take the medication as

ordered.

She can take the medication when she is nervous and feels she needs it.

She can take two pills before school and one pill at dinner, which will be easier

for her to remember.

Her mother can be responsible for reminding her when it is time to take her

medication.

Diabetes insipidus is a disorder of the

Anterior pituitary

Posterior pituitary

Adrenal cortex

Adrenal medulla

Which sign, when exhibited by a hospitalized child, should the nurse recognize as a

characteristic of diabetes insipidus?

Weight gain

Increased urine specific gravity

Increased urination

Serum sodium level of 130 mEq/L

What should the nurse include in the teaching plan for parents of a child with diabetes

insipidus who is receiving DDAVP?

Increase the dosage of DDAVP as the urine specific gravity (SG) increases.

Give DDAVP only if urine output decreases.

The child should have free access to water and toilet facilities at school.

Cleanse skin before administering the transdermal patch.

A child with GH deficiency is receiving GH therapy. What is the best time for the GH to be

administered?

At bedtime

After meals

Before meals

On arising in the morning

At bedtime

After meals

Before meals

On arising in the morning

A nurse is explaining growth hormone deficiency to parents of a child admitted to rule out this

problem. Which metabolic alteration that is related to growth hormone deficiency should the

nurse explain to the parent?

Hypocalcemia

Hypoglycemia

Diabetes insipidus.

Hyperglycemia

Diabetes insipidus.

Hyperglycemia

At what age is sexual development in boys and girls considered to be precocious?

Boys, 11 years; girls, 9 years

Boys, 12 years; girls, 10 years

Boys, 9 years; girls, 8 years

Boys, 10 years; girls, 9 1/2 years

What is the most appropriate intervention for the parents of a 6-year-old child with

precocious puberty?

Advise the parents to consider birth control for their daughter.

Explain the importance of having the child foster relationships with same-age

peers.

Assure the childs parents that there is no increased risk for sexual abuse because

of her appearance.

Counsel parents that there is no treatment currently available for this disorder.

A neonate is displaying mottled skin, has a large fontanel and tongue, is lethargic, and is

having difficulty feeding. The nurse recognizes that this is most suggestive of

Hypocalcemia

Hypothyroidism

Hypoglycemia

Phenylketonuria (PKU)

A common clinical manifestation of juvenile hypothyroidism is

Insomnia

Diarrhea

Dry skin

Accelerated growth

A goiter is an enlargement or hypertrophy of which gland?

Thyroid

Adrenal

Anterior pituitary

Posterior pituitary

Exophthalmos (protruding eyeballs) may occur in children with which condition?

Hypothyroidism

Hyperthyroidism

Hypoparathyroidism

Hyperparathyroidism

Hyperthyroidism

Hypoparathyroidism

Hyperparathyroidism

A neonate born with ambiguous genitalia is diagnosed with congenital adrenogenital

hyperplasia. Therapeutic management includes administration of

Vitamin D

Cortisone

Stool softeners

Calcium carbonate

Type 1 diabetes mellitus is suspected in an adolescent. Which clinical manifestation may be

present?

Moist skin

Weight gain

Fluid overload

Blurred vision

A parent asks the nurse why self-monitoring of blood glucose is being recommended for her

child with diabetes. The nurse should base the explanation on the knowledge that

It is a less expensive method of testing.

It is not as accurate as laboratory testing.

Children are better able to manage the diabetes.

The parents are better able to manage the disease.

What is the best time for the nurse to assess the peak effectiveness of subcutaneously

administered Regular insulin?

Two hours after administration

Four hours after administration

Immediately after administration

Thirty minutes after administration

What is the primary concern for a 7-year-old child with type 1 diabetes mellitus who asks his

mother not to tell anyone at school that he has diabetes?

The childs safety

The privacy of the child

Development of a sense of industry

Peer group acceptance

What is the best nursing action when a child with type 1 diabetes mellitus is sweating,

trembling, and pale?

Offer the child a glass of water.

Give the child 5 units of regular insulin subcutaneously.

Give the child a glass of orange juice.

Give the child glucagon subcutaneously.

Which sign is the nurse most likely to assess in a child with hypoglycemia?

Urine positive for ketones and serum glucose greater than 300 mg/dL

Normal sensorium and serum glucose greater than 160 mg/dL

Irritability and serum glucose less than 60 mg/dL

Increased urination and serum glucose less than 120 mg/dL

Normal sensorium and serum glucose greater than 160 mg/dL

Irritability and serum glucose less than 60 mg/dL

Increased urination and serum glucose less than 120 mg/dL

When would a child diagnosed with type 1 diabetes mellitus most likely demonstrate a

decreased need for insulin?

During the honeymoon phase

During adolescence

During growth spurts

During minor illnesses

What should a nurse advise the parents of a child with type 1 diabetes mellitus who is not

eating as a result of a minor illness?

Give the child half his regular morning dose of insulin.

Substitute simple carbohydrates or calorie-containing liquids for solid foods.

Give the child plenty of unsweetened, clear liquids to prevent dehydration.

Take the child directly to the emergency department.

Which is the nurses best response to the parents of a 10-year-old child newly diagnosed with

type 1 diabetes mellitus who are concerned about the childs continued participation in soccer?

Consider the swim team as an alternative to soccer.

Encourage intellectual activity rather than participation in sports.

It is okay to play sports such as soccer unless the weather is too hot.

Give the child an extra 15 to 30 g of carbohydrate snack before soccer practice.

Which comment by a 12-year-old child with type 1 diabetes indicates deficient knowledge?

I rotate my insulin injection sites every time I give myself an injection.

I keep records of my glucose levels and insulin sites and amounts.

Ill be glad when I can take a pill for my diabetes like my uncle does.

I keep Lifesavers in my school bag in case I have a low-sugar reaction.

Chapter 49 Nursing Care of the Child With an Alteration in Genetics

MULTIPLE CHOICE

A parent whose child has been diagnosed with a cognitive deficit should be counseled that

intellectual impairment

Is usually due to a genetic defect

May be caused by a variety of factors

Is rarely due to first trimester events

Is usually caused by parental intellectual impairment

A parent asks the nurse why a developmental assessment is being conducted for a child during

a routine well-child visit. The nurse answers based on the knowledge that routine developmental

assessments during well-child visits are

Not necessary unless the parents request them

The best method for early detection of cognitive disorders

Frightening to parents and children and should be avoided

Valuable in measuring intelligence in children

Not necessary unless the parents request them

The best method for early detection of cognitive disorders

Frightening to parents and children and should be avoided

Valuable in measuring intelligence in children

The father of a child recently diagnosed with developmental delay is very rude and hostile

toward the nurses. This father was cooperative during the childs evaluation a month ago. What is

the best explanation for this change in parental behavior?

The father is exhibiting symptoms of a psychiatric illness.

The father may be abusing the child.

The father is resentful of the time he is missing from work for this appointment.

The father is experiencing a symptom of grief.

An appropriate nursing diagnosis for a child with a cognitive dysfunction who has a limited

ability to anticipate danger is

Impaired social interaction

Deficient knowledge

Risk for injury

Ineffective coping

Anticipatory guidance for the family of a preadolescent with a cognitive dysfunction should

include information about

Institutional placement

Sexual development

Sterilization

Clothing

What should be the major consideration when selecting toys for a child with an intellectual or

developmental disability?

Safety

Age appropriateness

Ability to provide exercise

Ability to teach useful skills

Appropriate interventions to facilitate socialization of the cognitively impaired child include

Providing age-appropriate toys and play activities

Providing peer experiences, such as scouting, when older

Avoiding exposure to strangers who may not understand cognitive development

Emphasizing mastery of physical skills because they are delayed more often

than verbal skills

A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed

nasal bridge, protruding tongue, and transverse palmar creases. These findings are most

suggestive of

Microcephaly

Down syndrome

Cerebral palsy

Fragile X syndrome

The infant with Down syndrome is closely monitored during the first year of life for what

serious condition?

Thyroid complications

Orthopedic malformations

Dental malformation

Cardiac abnormalities

Many of the physical characteristics of Down syndrome present feeding problems. Care of

the infant should include

Delaying feeding solid foods until the tongue thrust has stopped

Modifying diet as necessary to minimize the diarrhea that often occurs

Providing calories appropriate to childs age

Using special bottles that may assist the infant with feeding

Delaying feeding solid foods until the tongue thrust has stopped

Modifying diet as necessary to minimize the diarrhea that often occurs

Providing calories appropriate to childs age

Using special bottles that may assist the infant with feeding

What action is contraindicated when a child with Down syndrome is hospitalized?

Determine the childs vocabulary for specific body functions.

Assess the childs hearing and visual capabilities.

Encourage parents to leave the child alone for extended periods of time.

Have meals served at the childs usual meal times.

The child with Down syndrome should be evaluated for which condition before participating

in some sports?

Hyperflexibility

Cutis marmorata

Atlantoaxial instability

Speckling of iris (Brushfield spots)

A nurse is giving a parent information about autism. Which statement made by the parent

indicates understanding of the teaching?

Autism is characterized by periods of remission and exacerbation.

The onset of autism usually occurs before 3 years of age.

Children with autism have imitation and gesturing skills.

Autism can be treated effectively with medication.

What should the nurse keep in mind when planning to communicate with a child who has

autism?

The child has normal verbal communication.

Expect the child to use sign language.

The child may exhibit monotone speech and echolalia.

The child is not listening if she is not looking at the nurse.

Developmental delays, self-injury, fecal smearing, and severe temper tantrums in a preschool

child are symptoms of

Down syndrome

Intellectual disability

Psychosocial deprivation

Separation anxiety

Throughout their life span, cognitively impaired children are less capable of managing

environmental challenges and are at risk for

Nutritional deficits

Visual impairments

Physical injuries

Psychiatric problems

Which statement best describes Fragile X syndrome?

Chromosomal defect affecting only females

Chromosomal defect that follows the pattern of X-linked recessive disorders

Second most common genetic cause of cognitive impairment

Most common cause of noninherited cognitive impairment

Chromosomal defect that follows the pattern of X-linked recessive disorders

Second most common genetic cause of cognitive impairment

Most common cause of noninherited cognitive impairment

The nurse is providing counseling to the mother of a child diagnosed with fragile X

syndrome. She explains to the mother that fragile X syndrome is

Most commonly seen in girls

Acquired after birth

Usually transmitted by the male carrier

Usually transmitted by the female carrier

The best setting for daytime care for a 5-year-old autistic child whose mother works is

Private day care

Public school

His own home with a sitter

A specialized program that facilitates interaction by use of behavioral methods

Parents have learned that their 6-year-old child has autism. The nurse may help the parents to

cope by explaining that the child may

Have an extremely developed skill in a particular area

Outgrow the condition by early adulthood

Have average social skills

Have age-appropriate language skills

A child with autism hospitalized with asthma. The nurse should plan care so that the

Parents expectations are met.

Childs routine habits and preferences are maintained.

Child is supported through the autistic crisis.

Parents need not be at the hospital.

MULTIPLE RESPONSE

You are the nurse assessing a 3-year-old child who has characteristics of autism. Which

observed behaviors are associated with autism? Select all that apply.

The child flicks the light in the examination room on and off repetitiously.

The child has a flat affect.

c.The child demonstrates imitation and gesturing skills.

Mother reports the child has no interest in playing with other children.

The child is able to make eye contact.

The child flicks the light in the examination room on and off repetitiously.

The child has a flat affect.

The child demonstrates imitation and gesturing skills.

Mother reports the child has no interest in playing with other children.

The child is able to make eye contact.

A nurse is assessing a newborn for facial feature characteristics associated with fetal alcohol

syndrome: Which characteristics should the nurse expect to assess? Select all that apply.

Short palpebral fissures

Smooth philtrum

Low set ears

Inner epicanthal folds

e.Thin upper lip

A nurse should plan to implement which interventions for a child admitted with inorganic

failure to thrive? Select all that apply.

Observation of parent-child interactions

Assignment of different nurses to care for the child from day to day

Use of 28 calorie per ounce concentrated formulas

Administration of daily multivitamin supplements

Role modeling appropriate adult-child interactions

COMPLETION

Unlike fragile X syndrome, which affects primarily males, __________ (RS) is almost

exclusively linked to female gender.

Chapter 50 Nursing Care of the Child With an Alteration in Behavior, Cognition, or Development

MULTIPLE CHOICE

Which sign or symptom is likely to be manifested by an adolescent with a depressive

disorder?

Abuse of alcohol

Impulsivity and distractibility

Carelessness and inattention to details

Refusal to leave the house

Which statement about suicide is correct?

Children younger than 10 years of age do not attempt suicide.

Suicide risk decreases with age.

Suicide is usually an isolated event in a school community.

The prevalence of suicide attempts is higher among males.

The best response for the nurse to make to an adolescent who states, I am very sad. I wish I

was not alive. is

Everyone feels sad once in a while.

You are just trying to escape your problems.

Have you told your parents how you feel?

Have you thought about hurting yourself?

You are just trying to escape your problems.

Have you told your parents how you feel?

Have you thought about hurting yourself?

The long-term treatment plan for an adolescent with an eating disorder focuses on

Managing the effects of malnutrition

Establishing sufficient caloric intake

Improving family dynamics

Restructuring perception of body image

A parent of a child with an anxiety disorder states, I dont know how my child developed this

problem. On what information should the nurse base a response?

Genetic factors, hormonal imbalances, and societal influences all contribute to

the development of anxiety disorders in children.

Like many conditions affecting children, the etiology of anxiety disorders is

unknown.

The majority of anxiety disorders have a clear pattern of genetic inheritance.

Dysfunctional family patterns are usually identified as the cause of an anxiety

disorder.

In counseling an adolescent who is abusing alcohol, the nurse explains that alcohol abuse

primarily affects which organ of the body?

Heart

Liver

Brain

Lungs

The outpatient nurse understands that the phase of substance abuse characterized by a 14-yearold

child admitting to using marijuana every day with friends after attending school is

Experimentation

Early drug use

True drug addiction

Severe drug addiction

The school nurse observes an unkempt child dressed in inappropriate clothing who repeatedly

asks for food. About which problem is the nurse concerned?

Physical abuse

Physical neglect

Emotional abuse

Sexual abuse

A child who has symptoms of irritable mood, changes in sleep and appetite patterns, decreased

self-esteem, and disengagement from family and friends lasting 3 weeks meets the criteria for

which depressive disorder?

Major depressive disorder

Dysthymic disorder

Cyclothymic disorder

Panic disorder

What is the goal of therapeutic management for a child diagnosed with ADHD?

Administer stimulant medications.

Assess the child for other psychosocial disorders.

Correct nutritional imbalances.

Reduce the frequency and intensity of unsocialized behaviors.

Which behavior demonstrated by an adolescent should alert the school nurse to a problem of

substance abuse?

States feelings of worthlessness

Increased desire for social conformity

Does not feel need for peer approval

Deterioration of relationships with family members

Which behavior verbalized by a school-age child should alert the school nurse to a problem

of possible obsessive-compulsive disorder (OCD)?

States feelings of worthlessness and sadness everyday

Feels need to ride a bike around the tree in front of the house seven times every

day before entering the house

Recurrent episodes of chest pain, heart palpations, and shortness of breath when

entering the computer classroom

Deterioration of relationships with family members

Which finding noted by the nurse on a physical assessment is most suggestive that a child has

been sexually abused?

Swelling of the genitalia and pain on urination

Smooth philtrum and thin upper lip

Speech and physical development delays

History of constipation, drowsiness, and constricted pupils

Swelling of the genitalia and pain on urination

Smooth philtrum and thin upper lip

Speech and physical development delays

History of constipation, drowsiness, and constricted pupils

Which manifestation is atypical of ADHD?

Talking incessantly

Blurting out the answers to questions before the questions have been completed

c.Acting withdrawn in social situations

Fidgeting with hands or feet

Blurting out the answers to questions before the questions have been completed

Acting withdrawn in social situations

Fidgeting with hands or feet

MULTIPLE RESPONSE

The parents of a teen suspect their child is using amphetamines. Manifestations of

amphetamine use include (select all that apply)

Weight gain

Excessive talking and activity

Excessive sleeping

Insomnia

Agitation

Insomnia

Agitation

A nurse working on the pediatric unit should be aware that children admitted with which of

the following assessment findings are suggestive of physical child abuse? Select all that apply.

Bruises in various stages of healing

Bruises over the shins or bony prominences

Burns on the palms of the hands

A fracture of the right wrist from a sports accident

Rib fractures in an infant

The nurse is aware that suicide risk increases if the child displays which characteristics? Select

all that apply.

Previous suicide attempt

No previous exposure to violence in the home

Recent loss

Effective social network

History of physical abuse

COMPLETION

The rapid onset of physical, cognitive, and emotional symptoms that results in chest pain,

shortness of breath, and the signs of impending doom is known as ________________.

Chapter 51 Nursing Care During a Pediatric Emergency

MULTIPLE CHOICE

Which nursing action facilitates care being provided to a child in an emergency situation?

Encourage the family to remain in the waiting room.

Include parents as partners in providing care for the child.

Always reassure the child and family.

Give explanations using professional terminology.

The father of a child in the emergency department is yelling at the physician and nurses.

Which action is contraindicated in this situation?

Provide a nondefensive response.

Encourage the father to talk about his feelings.

Speak in simple, short sentences.

Tell the father he must wait in the waiting room.

What is an appropriate nursing intervention for a 6-month-old infant in the emergency

department?

Distract the infant with noise or bright lights.

Avoid warming the infant.

Remove any pacifiers from the baby.

Encourage the parent to hold the infant.

Which action should the nurse working in the emergency department implement in order to

decrease fear in a 2-year-old child?

Keep the child physically restrained during nursing care.

Allow the child to hold a favorite toy or blanket.

Direct the parents to remain outside the treatment room.

Let the child decide whether to sit up or lie down for procedures.

Which nursing action is most appropriate to assist a preschool-age child in coping with the

emergency department experience?

Explain procedures and give the child at least 1 hour to prepare.

Remind the child that she is a big girl.

Avoid the use of bandages.

Use positive terms and avoid terms such as shot and cut.

Which action should the nurse incorporate into a care plan for a 14-year-old child in the

emergency department?

Limit the number of choices to be made by the adolescent.

Insist that parents remain with the adolescent.

Provide clear explanations and encourage questions.

Give rewards for cooperation with procedures.

Limit the number of choices to be made by the adolescent.

Insist that parents remain with the adolescent.

Provide clear explanations and encourage questions.

Give rewards for cooperation with procedures.

The emergency department nurse notices that the mother of a young child is making a lot of

phone calls and getting advice from her friends about what she should do. This behavior is an

indication of

Stress

Healthy coping skills

Attention-getting behaviors

Low self-esteem

Attention-getting behaviors

Low self-esteem

A preschool child in the emergency department has a respiratory rate of 10 breaths per minute.

How should the nurse interpret this finding?

The child is relaxed.

Respiratory failure is likely.

This child is in respiratory distress.

The childs condition is improving.

The nurse observes abdominal breathing in a 2-year-old child. What does this finding

indicate?

Imminent respiratory failure

Hypoxia

Normal respiration

Airway obstruction

What should be the emergency department nurses next action when a 6-year-old child has a

systolic blood pressure of 58 mm Hg?

Alert the physician about the systolic blood pressure.

Comfort the child and assess respiratory rate.

Assess the childs responsiveness to the environment.

Alert the physician that the child may need intravenous fluids.

You are the nurse caring for a child who is diagnosed with septic shock. He begins to

develop an dysrhythmia and hemodynamic instability. Endotracheal intubation is necessary. The

physician feels that cardiac arrest may soon develop. What drug do you anticipate the physician

will order?

Atropine sulfate

Epinephrine

Sodium bicarbonate

Inotropic agents

You are the nurse working triage in the emergency department. A school-age child is brought

in for treatment, carried by her mother. What is part of a primary assessment that should be

performed first on this child?

Determine level of consciousness.

Obtain a health history.

Obtain a full set of vital signs.

Evaluate for pain.

What is the goal of the initial intervention for a child in cardiopulmonary arrest?

Establishing a patent airway

Determining a pulse rate

Removing clothing

Reassuring the parents

What is the nurses immediate action when a child comes to the emergency department with

sweating, chills, and fang bite marks on the thigh?

Secure antivenin therapy.

Apply a tourniquet to the leg.

Ambulate the child.

Reassure the child and parent.

Apply a tourniquet to the leg.

Ambulate the child.

Reassure the child and parent.

How should the nurse instruct the mother who calls the emergency department because her 9-

year-old child has just fallen on his face and one of his front teeth fell out?

Put the tooth back in the childs mouth and call the dentist right away.

Place the tooth in milk or water and go directly to the emergency department.

Gently place the tooth in a plastic zippered bag until she makes a dental

appointment.

Clean the tooth and call the dentist for an immediate appointment.

A 3-year-old is brought to the emergency department by ambulance after her body was found

submerged in the family pool. The child has altered mental status and shallow respirations. She

did not require resuscitative interventions. Which condition should the nurse monitor first in this

child?

Neurologic status

Hypothermia

Hypoglycemia

Hypoxia

Assessment of a child with a submersion injury focuses on which system?

Cardiovascular

Respiratory

Neurologic

Gastrointestinal

Which is the most critical element of pediatric emergency care?

Airway management

Prevention of neurologic impairment

Maintaining adequate circulation

Supporting the childs family

Which observations made by an emergency department nurse raises the suspicion that a 3-

year-old child has been maltreated?

The parents are extremely calm in the emergency department.

The injury is unusual for a child of that age.

The child does not remember how he got hurt.

The child was doing something unsafe when the injury occurred.

In which situation is the administration of milk or water indicated after ingestion?

The child is suspected of ingesting lead paint chips.

The child ingested approximately 15 tablets of baby aspirin.

The child ingested an over-the-counter product containing acetaminophen.

The child ingested an acid or alkali.

Which initial assessment made by the triage nurse suggests that a child requires immediate

intervention?

The child has thick yellow rhinorrhea.

The child has a frequent nonproductive cough.

The childs oxygen saturation is 95% by pulse oximeter.

The child is grunting.

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