Chapter 49 Maternal and Child Health Nursing 7th Edition

Chapter 49  Maternal and Child Health Nursing 7th Edition

Complete Chapter Questions And Answers
 

Sample Questions

1.
The nurse is planning care for a preschool-age child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this patient’s musculoskeletal status?
A)
Risk for self-care deficit related to impaired mobility
B)
Risk for disuse syndrome related to spasticity of muscle groups
C)
Impaired verbal communication related to neurologic impairment
D)
Risk for delayed growth and development related to activity restriction
Ans:
B

Feedback:

Children with cerebral palsy need promotion of any function that is not already impaired to prevent further loss of function and allow them to master the highest level of self-care. Learning to be ambulatory is an important part of self-care because it pays a large role in determining how independent the child can become. Walking can be difficult for the child to master because of lack of muscle coordination. Preventing contractures is also important to maintain motor function. Risk for self-care deficit focuses on self-care measures such as dressing, toothbrushing, bathing, and toileting, so the child can not only gain self-esteem by accomplishing these tasks but also achieve optimal independence. Impaired verbal communication addresses focuses on speech and not necessary the entire musculoskeletal status. The risk for delayed growth and development focuses on the child’s potential inability to pursue stimulating activities and surroundings because of not being fully mobile.

2.
An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient?
A)
Numbness of fingers and decreased temperature
B)
Increased pulse rate and decreased blood pressure
C)
Increased temperature and decreased respiratory rate
D)
Decreased level of consciousness and increased respiratory rate
Ans:
C

Feedback:

Manifestations of increased intracranial pressure include increased body temperature and decreased respiratory rate. Pulse rate slows, and the blood pressure increases.

3.
The nurse is planning a program for a community that focuses on the 2020 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? (Select all that apply.)
A)
Ensuring a diet adequate in vitamins and protein
B)
Use of helmets for bicycle and motorcycle safety
C)
Learning the signs and symptoms of inflammatory disorders
D)
Practicing good hand washing technique and infection control
E)
Importance of proper emergency care to protect the head and neck
Ans:
B, D, E

Feedback:

Nurses can help the nation achieve the 2020 National Health Goals through helping prevent neurologic injury by educating children and parents about the use of helmets for bicycle and motorcycle safety, by administering and teaching paramedical personnel to administer safe care at accident scenes so children’s heads and necks are protected, and by decreasing the possible spread of bacterial meningitis through good hand washing and infection control precautions in hospitals. Interventions about diet and manifestations of inflammatory disorders will not help achieve the 2020 National Health Goals.

4.
A postpartum patient is upset that the baby was born with a congenital port-wine birthmark on the skin of the upper part of the right side of the face. What should the nurse explain to the mother about this birthmark?
A)
“The birthmark is a part of a syndrome that can be cured with medication.”
B)
“The birthmark can be removed surgically so the child will develop normally.”
C)
“The birthmark is a concentration of melanin in the skin and causes cosmetic problems.”
D)
“The baby may have some numbness on the left side of the body because of the birthmark.”
Ans:
D

Feedback:

Sturge-Weber syndrome is characterized by a congenital port-wine birthmark on the skin of the upper part of the face that follows the distribution of the first division of the fifth cranial nerve. Because of involvement of the meningeal blood vessels, blood flow can be sluggish, and anoxia may develop in some portions of the cerebral cortex. The child will develop symptoms of numbness on the side opposite the lesion from destruction of motor neurons. This syndrome cannot be cured with medication. Removing the birthmark with surgery will not correct the long-term effects of the problem. The birthmark is not caused by a concentration of melanin in the skin. This problem has the potential to cause more than cosmetic health problems.

5.
The parents of a child with a thoracic-level spinal injury are anxious to learn the long-term prognosis for their child and ask if the child will walk again. How should the nurse respond to the parents?
A)
“Damage usually progresses after the first week.”
B)
“It is most unlikely that your son will ever walk again.”
C)
“What has the physician said about your son’s recovery?”
D)
“It will be several weeks before an answer to your question is possible.”
Ans:
D

Feedback:

Spinal injuries result when the spinal cord becomes compressed or severed by the vertebrae; further cord damage can result from hemorrhage, edema, or inflammation at the injury site as the blood supply becomes impeded. Predictions of useful body function cannot be made accurately at the time of the injury. Three phases of recovery must first take place. The nurse cannot accurately say that damage will progress after the first week. The nurse has no way of knowing if the child will walk again. The nurse can answer the parent’s question without finding out what the physician has said about the child’s recovery.