Chapter 1 A Framework for Maternal and Child Health Nursing
1. For which reasons would a nurse review infant mortality statistics in the United States?
(Select all that apply.)
A) Measures the quality of pregnancy care
B) Reviews information on overall nutrition
C) Compares health with those of other states
D) Determines infant health and available care
E) Provides an index of the country's general health
Ans: A, B, D, E
Feedback:
Infant mortality statistics provide an index of a country's general health, measures the
quality of pregnancy care, provides information on overall nutrition, and determines
infant health and available care. Infant mortality statistics compares the health with
those of other countries and not with those of other states.
2. The nurse is providing care in an organization that supports the maternal and child care
continuum. Which type of patient care area is an example of this approach?
A) Primary care
B) Team nursing
C) Case management
D) Family-centered care
Ans: D
Feedback:
Keeping the family at the center of care is important because the level of a family's
functioning is important to the health status of its members. A healthy family establishes
an environment conducive to growth and health-promoting behaviors to sustain family
members during crises. A family-centered approach enables nurses to better understand
individuals and their effect on others and, in turn, to provide more holistic care. Primary
nursing, team nursing, and case management do not necessary take into consideration
the maternal and child care continuum.
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3. Which actions should the nurse perform when supporting the goals of maternal and
child health care? (Select all that apply.)
A) Advocates protecting the rights of the mother and fetus
B) Teaches family members interventions to improve health
C) Adheres to principles that focus on the needs of the mother
D) Encourages maternal hospitalization to regain strength and stamina
E) Assesses family members for strengths and specific needs or challenges
Ans: A, B, E
Feedback:
Actions that the nurse should perform when supporting the goals of maternal and child
health care include advocating the rights for the mother and fetus, teaching health
promotion interventions, and assessing the family for strengths and specific needs or
challenges. Adhering to principles that focus on the needs of the mother and
encouraging maternal hospitalization to regain strength and stamina are not actions that
support the goals of maternal and child health care.
4. The nurse is reviewing the 2020 National Health Goals and notes that which is a focus
of these goals?
A) Health promotion and disease prevention
B) Early diagnosis of chronic health problems
C) Effective use of medication to treat disease
D) Reduce the cost of health care and medications
Ans: A
Feedback:
The 2020 National Health Goals are intended to help citizens more easily understand the
importance of health promotion and disease prevention and to encourage wide
participation in improving health in the next decade. These goals do not focus on the
early diagnosis of chronic problems, use of medications to treat disease, or reduce the
cost of health care and medications.
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5. The nurse has noticed a change in the type of care needed to support maternal and child
health issues. What does the nurse realize as reasons for the changes in care? (Select all
that apply.)
A) Smaller families
B) Less domestic violence
C) More employed mothers
D) Stable home environments
E) More single-parent families
Ans: A, C, E
Feedback:
Nursing care for maternal and child is changing because families are smaller, more
mothers are employed out of the home, and there are more single-parent families. There
is an increase in domestic violence, and families are less stable and more mobile, which
influences homelessness.
6. During an assessment, the nurse asks a patient from a non-English-speaking culture
which types of home remedies and herbs the patient uses for health care. What is the
purpose of asking the patient this question?
A) Analyze for herb–drug interactions
B) Understand the patient's philosophy of alternative health care
C) Determine the types of medications the patient will need to be prescribed
D) Explain to the physician the patient's preference for nontraditional medicine
approaches
Ans: A
Feedback:
Assessing what alternative measures are being used is important because the action of
an herb can interfere with prescribed medications. Assessing the use of herbal remedies
is not done to understand the patient's philosophy of alternative health care, determine
the types of medications the patient will need to be prescribed, or explain the patient's
preferences for nontraditional medicine approaches to the physician.
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7. The nurse notes that statistics on maternal mortality had improved but are again
becoming elevated. What does the nurse realize as a reason for this change in maternal
mortality rates?
A) Earlier prenatal care
B) Gestational hypertension
C) Increased vaginal deliveries
D) Treatment for chronic diseases
Ans: B
Feedback:
This increasing rate in maternal mortality is associated with more cesarean births, more
gestational hypertension related to preexisting hypertensive disorders, and lack of health
insurance for many Americans. This increase is not because of earlier prenatal care,
increased vaginal deliveries, or treatment for chronic diseases.
8. A new mother asks the nurse if all of the new baby's injections can be given in one visit
because the mother is losing income from missing work because of the office visits.
What does this new mother's issue indicate to the nurse?
A) The mother needs to find an alternative employer.
B) The mother's income is more important that the baby's health.
C) Missing work does not support the baby's health maintenance visits.
D) The federal government needs to do more to support well-baby visits.
Ans: C
Feedback:
An area that needs additional research is finding effective stimuli to encourage women
to bring children for health maintenance visits. The mother losing income because of
missing work for well-baby visits will deter health maintenance visits for the baby going
forward. This mother's issue does not indicate that the mother needs to find another job,
that the mother's income is more important that the baby's health, or that the federal
government needs to do more to support well-baby visits.
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9. The nurse works in a maternal and child care area that supports health promotion.
Which activities will the nurse perform to support this philosophy of health care?
(Select all that apply.)
A) Planning care
B) Patient teaching
C) Family counseling
D) New mother advocacy
E) Identifying nursing diagnoses
Ans: B, C, D
Feedback:
Extensive changes in the scope of maternal and child health nursing have occurred as
health promotion has become a greater priority in care. The nursing activities for health
promotion include teaching, counseling, and advocacy. Planning care and identifying
nursing diagnoses are a part of the nursing process and not specific to health promotion.
10. During a care conference, a nurse provides everyone with a copy of the latest research
on improving the success of breastfeeding for first-time mothers. Which Quality &
Safety Education for Nurses competency does this nurse's action support?
A) Quality improvement
B) Patient-centered care
C) Evidence-based practice
D) Teamwork and collaboration
Ans: C
Feedback:
Providing research material supports the Quality & Safety Education for Nurses
competency of evidence-based practice because the nurse is integrating the best current
evidence with clinical expertise and patient/family preferences and values for delivery
of optimal health care. Providing research evidence does not support the Quality &
Safety Education for Nurses competencies of quality improvement, patient-centered
care, or teamwork and collaboration.
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11. The nurse is caring for a mother who has just given birth to twins of 28 weeks gestation,
each weighing 2 kg. What is the health risk for the mother and the twins?
A) Child mortality
B) Neonatal death
C) Infant mortality
D) Maternal mortality
Ans: B
Feedback:
Neonatal death reflects the quality of care available to women during pregnancy and
childbirth and the quality of care available to infants during the first month of life. The
leading causes of death during this time are prematurity with associated low birth
weight. Child mortality is the number of people who die during childhood years. Infant
mortality is the number of infants who die before the age of 1 year. Maternal mortality
is the number of women who die from activities related to childbirth.
12. The nurse is planning an educational session for community members to address the
issue of school-age child mortality. Which topic should the nurse identify as the highest
priority for this population?
A) Cancer
B) Assault
C) Suicide
D) Accidents
Ans: D
Feedback:
For the school-age child between the ages of 5 and 14 years, the number one cause of
mortality is from unintentional injuries or accidents. Other top five causes for child
mortality include cancer, assault, and suicide.
13. While providing care to a child, the nurse informs the parents about the treatment plans
and helps the parents make decisions about the child's care needs. What do this nurse's
actions support?
A) Autonomy
B) Empowerment
C) Accountability
D) Informed consent
Ans: B
Feedback:
Nurses promote empowerment of parents and children by respecting their views and
concerns, regarding parents as important participants in their own or their child's health,
keeping them informed, and helping and supporting them to make decisions about care.
The nurse's actions are not being done to support autonomy, accountability, or informed
consent.
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14. The nurse has been hired to provide care to patients on a maternal and child unit. What
will the nurse use to as a guide to legally provide care to this patient population?
A) Code of ethics
B) Nursing research
C) Standards of practice
D) Evidence-based guidelines
Ans: C
Feedback:
Understanding standards of care can help nurses practice within appropriate legal
parameters. The Code of Ethics will help with ethical situations. Nursing research and
evidence-based guidelines will help with providing care that is based upon best
practices.
15. The nurse is providing care to a new mother and infant according to the Quality &
Safety Education for Nurses competency approach. Which action should the nurse
perform to demonstrate the skill for the competency of safety?
A) Assess the mother for preferences based on personal values.
B) Ensure the mother and newborn have intact identification bands.
C) Introduce all members of the care team to the mother and family.
D) Document patient care using computerized spreadsheets and forms.
Ans: B
Feedback:
Action to demonstrate the skill of the competency of safety is to ensure that the mother
and newborn have intact identification bands. Assessing the mother for preferences
based on personal values is the skill associated with patient-centered care. Introducing
all members of the care team to the mother and family is the skill associated with
teamwork and collaboration. Documenting patient care using computerized spreadsheets
and forms is the skill associated with quality improvement.
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Chapter 2 Diversity and Maternal Child Nursing
1. A school-age child, a member of a family with a mother, father, and toddler, is
hospitalized. The father is employed outside of the home, and the mother stays at home
with the other child. The mother is challenged with supporting both children at this time.
What should the nurse suggest to the mother?
A) Place the toddler in day care.
B) Suggest the father take time off to help.
C) Ask extended family members to help out during this time.
D) Visit with the patient after the father comes home from work.
Ans: C
Feedback:
In a time of crisis, the nuclear family is challenged because there are few family
members to share the burden or look at a problem objectively. The nurse should suggest
that the family locate and reach out to support people in their extended family during a
crisis. Placing the toddler in day care and suggesting the father take time off to help
might negatively impact the family's financial situation and would be inappropriate for
the nurse to suggest these options. The option of visiting the school-age child after the
father comes home from work may not support the child adequately during the
hospitalization.
2. A preadolescent patient, a member of a single-parent family, has abdominal pain and the
health care provider suspects that an appendectomy might need to be performed. The
patient's father is asking for a second opinion, whereas the mother tells the nurse to do
whatever needs to be done to help the patient. What does the nurse need to assess before
moving forward with planning care for this patient?
A) Permission to miss school
B) Identify the custodial parent
C) The type of health insurance
D) Plans for help upon discharge
Ans: B
Feedback:
The nurse needs to identify who is the custodial parent. This is especially important
when consent forms for care need to be signed. Once this information is obtained, the
nurse needs to clearly document it in the patient's medical record. Permission to miss
school, health insurance, and needs after discharge do not necessarily need to be
assessed prior to planning care for the patient.
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3. During a family assessment, the nurse learns that the male parent smokes. What should
the nurse do with this information to support the 2020 National Health Goals?
A) Document the information in the medical record.
B) Explain that smoking can cause long-term health problems.
C) Ask if the male parent has made any efforts towards smoking cessation.
D) Suggest that smoking be done away from other family members because of health
concerns.
Ans: C
Feedback:
One of the 2020 National Health Goals is to increase the percentage of adult smokers
aged 18 years and older attempting to stop smoking from 48.3% to 80%. To support this
goal, the nurse should ask the parent if any efforts toward smoking cessation have been
taken. The nurse needs to do more than just document the information. Explaining that
smoking can cause long-term health problems may not be an effective strategy to
encourage the parent to stop smoking. Suggesting that smoking be done away from
other family members is assuming that the parent is smoking with the family members
present.
4. During a family assessment, it is identified that the mother is unemployed but stays at
home to prepare meals, monitor medication doses, and comfort the children with
emotional issues. The father works outside of the home and pays the bills. Which terms
should the nurse use to document the role of the father in this family? (Select all that
apply.)
A) Provider
B) Nurturer
C) Culture bearer
D) Health manager
E) Financial manager
Ans: A, E
Feedback:
The provider is considered the person who brings home the money, which would be the
father because he works outside of the home. The person who pays the bills is
considered the financial manager. The nurturer would be the one who makes the meals
or the mother in this situation. The health manager is also the mother because she is the
person who monitors medication doses. There is no evidence to support that either the
mother or father function in the role as culture bearer.
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5. The nurse is completing an assessment of a family with a preschool-age child. Which
areas should the nurse focus when instructing the parents on tasks needed during this
stage of family development? (Select all that apply.)
A) Prevention of accidental injuries
B) Importance of child's socialization
C) Promoting health through immunizations
D) Socialization through sporting events
E) Need for dental care and health assessments
Ans: A, B
Feedback:
In the stage of family development with a preschool-age child, the parent's tasks are to
prevent accidental injuries and begin the child's socialization. Socialization through
sporting events, promoting health through immunizations, and the need for dental care
and health assessments are family responsibilities for the family with a school-age child.
6. The nurse is caring for a school-age child whose mother works two jobs, father is away
from the home during the week truck driving, and older brother has a part-time after
school job. The child will be hospitalized for several weeks for chemotherapy
treatments. Which nursing diagnosis should the nurse identify as being appropriate for
this family?
A) Impaired parenting
B) Parental role conflict
C) Health-seeking behaviors
D) Readiness for enhanced family coping
Ans: B
Feedback:
The diagnosis parental role conflict would address the parents' work responsibilities and
schedules and the relationship of work to the child's extended hospitalization. There is
no evidence to suggest that there is impaired parenting, health-seeking behaviors, or
readiness for enhanced family coping.
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7. The nurse is evaluating outcomes about a family's ability to care for an adolescent child
that is recovering from a spinal cord injury. Which statements indicate that this family is
transitioning in a healthy manner?
A) The patient states the injuries “messed up” the rest of his life.
B) The mother states the need to have a break at least once per week.
C) The patient states fewer episodes of nausea with changing position.
D) The father states the child's accident has brought the family closer together.
E) The mother states the ability to provide care for the child is becoming easier.
Ans: D, E
Feedback:
The statements that indicate that the family is able to care for an adolescent child that is
recovering from a spinal cord injury include the father's statement about the family
being brought closer together and the mother's statement about the care being easier to
provide. The patient's two statements do not address the family's ability to care for the
patient. The mother's statement about needing a break does not measure if the family is
able to care for the adolescent patient.
8. The nurse is planning outcomes of care for a family whose infant was born with a birth
defect. Which outcome statement would be the most appropriate for this family?
A) The parents will seek information regarding the birth defect.
B) The parents will limit involvement with extended family members.
C) The mother will return to work after 6 weeks as planned before the delivery.
D) The father will learn to care for the infant so that the mother can return to work.
Ans: A
Feedback:
The family has a new member that has a birth defect. The outcome statement that would
be most appropriate for the family would be for the parents to seek out information
about the birth defect. The parents limiting involvement with extended family members
may indicate that the family will be isolated. The father learning to care for the infant so
that the mother can return to work does not take into consideration if the father is
employed. The mother planning to return to work after 6 weeks as planned before the
delivery does not take into consideration the newborn's health care needs.
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9. The nurse is visiting a family with a toddler and school-age child. Which teaching
should the nurse provide to the parents that would be appropriate for both children?
A) Increased freedom
B) Actions to ensure safety
C) Encourage independent thinking
D) Importance of school experiences
Ans: B
Feedback:
The teaching that would support both of the children's needs would be to focus on
actions to ensure safety. Increased freedom would be appropriate for the adolescent.
Encourage independent thinking would be appropriate for the young adult. Importance
of school experiences would be appropriate for the school-age child but not for the
toddler.
10. A recently separated mother is overwhelmed with caring for three children under the
age of 5 years. The oldest child has been recently diagnosed with muscular dystrophy.
Which health care providers should the nurse consult to help the mother? (Select all that
apply.)
A) Dietician
B) Physician
C) Pharmacist
D) Social worker
E) Physical therapist
Ans: D, E
Feedback:
The mother is recently separated and is raising three children independently. The older
child is diagnosed with a chronic illness. The nurse should consult a social worker to
help identify resources that the mother and family need. The nurse should consult with a
physical therapist to help the oldest child attain or maintain the maximum level of
physical functioning. A dietician, physician, and pharmacist will not necessarily be of
assistance to the family at this time.
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11. A family of dual-parent employment with two school-age children has moved into a
community. During the home visit, the nurse overhears the children talking about
something on the Internet being more interesting than school work. What type of
information would be beneficial for the nurse to share with the parents at this time?
A) School clubs that meet on the weekends
B) Community activities planned specifically for after school
C) Names of the Internet providers that service the community
D) Local businesses seeking workers for part-time employment
Ans: B
Feedback:
The children of a dual-parent employment family might spend significant amounts of
time on the Internet. The parents may not be aware of what Internet sites the children
are frequenting. To reduce the amount of time spent alone on the Internet, the nurse
should provide the parents with information about community activities planned
specifically for after school. This could reduce the amount of time the children spend in
the Internet while waiting for parents to return home from work. School clubs that meet
on weekends will not help with the children spending time on the Internet during the
week. Providing the names of Internet service providers does not address the issue.
Local businesses seeking workers for part-time employment is inappropriate because the
children are of school age.
12. The nurse is visiting a family new to a community. The mother has a disability, and the
adolescent child is being treated for anorexia. What will the nurse do first when
assessing this family?
A) Construct an ecomap.
B) Complete a genogram.
C) Assess the home for safety.
D) Discuss the daughter's anorexia.
Ans: A
Feedback:
An ecomap documents the “fit” of a family into their community by diagramming the
family and community relationships. Because this family is new to the community, this
would be the best thing for the nurse to do first. A mark of families who are new to a
community is they have few community contacts because they have not formed these as
yet. A family with few connecting lines between its members and the community may
need increased nursing contact and support to remain a well family. A genogram is a
diagram that details family structure and provides information about the family's health
history and the roles of various family members across several generations. This might
be appropriate for the nurse to complete at a later time. Assessing the home for safety
and discussing the daughter's anorexia could also be done at a later time.
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13. The nurse has been working with a family on actions that strengthen loyalty between all
members. Which healthy family behavior has been the focus of the nurse's
interventions?
A) Division of labor
B) Physical maintenance
C) Socialization of family members
D) Maintenance of motivation and morale
Ans: D
Feedback:
In maintenance of motivation and morale, healthy families have pride in their family
and allow them to support each other during a crisis. Assessing for loyalty is one way to
measure this behavior. Division of labor focuses on family members dividing the
workload among family members and adjusting workloads as necessary. Physical
maintenance focuses on food, shelter, clothing, and health care. Socialization of family
members focuses on every family member feeling as a part of the family and interacting
with people outside of the family.
14. The nurse determines that a small nuclear family has achieved the family task of
division of labor. What did the nurse assess in this family to come to this conclusion?
A) Parents take the children out to meet the new neighbors.
B) Parents and children attend religious services every week.
C) Older children finish homework before watching television.
D) Mother cares for children while father works outside of the home.
Ans: D
Feedback:
The task of division of labor is when the workload is divided evenly between family
members. Parents taking children to meet the neighbors fulfill the task of family
member socialization. The family attending religious services every week fulfills the
task of member placement in society. Older children finishing homework before
watching television fulfills the task of maintenance of order.
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15. An extended family is experiencing a crisis. Excessive work demands have caused the
primary parents to work longer hours, but the grandmother who usually watches the
children after school is recovering from hip replacement surgery. What can the nurse
suggest to help this family through this period of time?
A) One parent reduces work hours.
B) Children go to the grandmother's house after school.
C) Identify another extended family member to assist while the grandmother
recovers.
D) Recommend the children learn independence and stay at home alone until a parent
arrives.
Ans: C
Feedback:
A positive aspect of the extended family is the availability of many people for child care
and support. The family needs to call on this strength and ask another family member to
help with the child support until the grandmother recovers. One negative aspect of the
extended family is reduced resources because of fewer wage earners. This is not the
case because both primary parents are working. Asking for one parent to reduce work
hours would be a negative suggestion. Having the children go to the grandmother's
home after school would negatively impact the grandmother's healing and is an
inappropriate suggestion to make at this time. Recommending the children learn
independence and stay at home alone could be a safety issue and would be an
inappropriate suggestion at this time.
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Chapter 3 The Childbearing and Childrearing Family in the Community
1. Which question should the nurse ask when assessing the sociocultural aspects of a
patient's family?
A) Citizenship
B) Occupation
C) Education level
D) Family structure
Ans: D
Feedback:
Family structure is a lifestyle area that is culturally determined. Citizenship, occupation,
and education level are influenced by culture but on an individual basis.
2. The nurse suspects that an adolescent patient from the inner city stereotypes other
people. Which statement did the patient make that caused the nurse to come to this
conclusion?
A) “Kids who study are just nerds.”
B) “All people who live in the suburbs drive big cars.”
C) “City people are smarter than those who live in the suburbs.”
D) “I stay away from people who live downtown because they look funny.”
Ans: B
Feedback:
Stereotyping is expecting a person to act in a characteristic way without regard to his or
her individual traits. Ethnocentrism is the belief one's own culture is superior to all
others as exemplified by the statement, “City people are smarter than those who live in
the suburbs.” Discrimination is treating people differently based on their physical or
cultural traits, or by performing an act. The statements that exemplify discrimination are
“kids who study are just nerds” and “I stay away from people who live downtown
because they look funny.”
3. A young patient tells the nurse that it is taboo to date before the age of 18 years. How
should the nurse interpret this patient's statement?
A) Everyone dates before the age of 18 years.
B) Dating before the age of 18 years is not permitted.
C) Dating before the age of 18 years can be done with permission.
D) Dating before the age of 18 years is permitted in large groups only.
Ans: B
Feedback:
A taboo is an action that is not acceptable to a culture. Dating before the age of 18 years
being taboo means that it is not permitted to be done. This does not mean that everyone
dates before the age of 18 years or that dating is done with permission or in large groups
only.
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4. Which nursing action supports a 2020 National Health Goal that addresses cultural
diversity?
A) Focusing on actions to enhance disease prevention
B) Reviewing actions to prevent accidents in the home environment
C) Discussing breastfeeding with a pregnant patient who is Hispanic
D) Analyzing the patient's compliance with health promotion activities
Ans: C
Feedback:
One 2020 National Health Goal for cultural diversity is to increase the proportion of
mothers who breastfeed their babies in the early postpartum period from a baseline of
43.5% to a target of 60.6%. Actions to enhance disease prevention, prevent accidents,
and comply with health promotion activities do not support the 2020 National Health
Goals for cultural diversity.
5. The nurse is preparing to assess a pregnant patient who is a member of a
non-English-speaking culture. Which areas should the nurse assess to address cultural
diversity? (Select all that apply.)
A) Pain
B) Time
C) Touch
D) Environment
E) Communication
Ans: A, B, C, E
Feedback:
When conducting an assessment, areas to include that address cultural diversity include
pain, time, touch, and communication. Environment is a global term that may or may
not be appropriate to for an assessment on cultural diversity.
6. The nurse is beginning an assessment with a pregnant patient from a
non-English-speaking culture. The interpreter is having difficulty understanding what
the patient is trying to say and the patient is becoming frustrated. Which nursing
diagnosis would be the most appropriate for this situation?
A) Fear
B) Anxiety
C) Powerlessness
D) Impaired verbal communication
Ans: D
Feedback:
For this patient, impaired verbal communication is because of the frustration that is
occurring between the patient, interpreter, and the nurse. There is no evidence to support
the diagnoses of fear, anxiety, or powerlessness with this patient.
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7. A pregnant patient from nondominant culture arrives for a prenatal examination is
escorted to an examination room. When asked to remove clothing and wear an
examination gown, the patient hesitates. What should the nurse do to ensure cultural
sensitivity in preparation for the examination?
A) Leave the room.
B) Stay in the room.
C) Assist with clothing removal.
D) Stand the distance of business space from the patient.
Ans: A
Feedback:
The patient may be from a culture that values modesty. Because the patient hesitated to
remove clothing while the nurse was in attendance, the nurse should leave the room to
permit the patient to change into the examination gown. Staying in the room, assisting
with clothing removal, or standing at the business distance from the patient does not
respect the patient's modesty.
8. The nurse teaches a pregnant patient from a nondominant culture that the health care
provider wants the patient to rest for several hours every afternoon. Which patient
statement indicates that teaching has been effective?
A) “I need to go to sleep a few hours earlier every night.”
B) “I can stay in bed for a few more hours every morning.”
C) “I can lie down before lunch and then again right after dinner.”
D) “I need to lie down after lunch and not get up until it's time to prepare dinner.”
Ans: D
Feedback:
The nurse is evaluating the patient's comprehension of teaching regarding obtaining rest
for several hours every afternoon. The statement about lying down after lunch and not
getting up until time to prepare dinner indicates the patient understands the teaching.
The other statements indicate that additional teaching is necessary because going to
sleep earlier each evening, lying in bed longer each morning, and resting before lunch
and after dinner do not demonstrate understanding of the health care provider's
instructions.
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9. The husband of a patient in active labor asks the nurse to phone him when the baby is
delivered because he needs to go to work. Which nursing response respects the
husband's culture?
A) Ask if he knows that he can stay with his wife during labor.
B) Tell him that all fathers now stay with their wives during labor.
C) Tell him he is missing out on the opportunity of a lifetime by leaving.
D) Insist he stay with his wife during labor because she will need his support.
Ans: A
Feedback:
When implementing care, the nurse needs to avoid forcing cultural values onto others.
The nurse needs to appreciate that such values are ingrained and usually very difficult to
change. The nurse also does not know the cultural value of work and should not assume
that the patient's delivery is more important that work in that family's culture. The
responses that “tell” or “insist” that the husband stay to support the patient do not
respect the family's culture.
10. A pregnant patient from a nondominant culture arrives 2 hours late for a scheduled
sonogram. What does this patient's behavior indicate to the nurse?
A) The patient is confused.
B) The patient does not wear a wrist watch.
C) Time orientation may be different for the patient's culture.
D) The patient's culture may focus on the past and not the future.
Ans: C
Feedback:
The patient who is from a culture that has a different time orientation than the dominant
culture will have difficulty adhering to time expectations. The patient not arriving for
the diagnostic test at the scheduled time does not mean that the patient is confused. It is
inconsequential if the patient does or does not wear a wrist watch. There is no enough
information to determine if the patient is from a culture that focuses on the past and not
the future.
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11. A pregnant patient from a nondominant culture explains that milk and dairy products
cannot be consumed for 2 months during the pregnancy because of the need to fast for
her religion. Which response should the nurse make after learning this information?
A) “I'm sure that you don't need to follow this while you are pregnant.”
B) “Avoiding milk and dairy products for 2 months will harm the fetus.”
C) “There are other food sources where you can obtain the nutrients that are in milk.”
D) “You must have a great deal of will power to avoid milk and dairy products for 2
months.”
Ans: C
Feedback:
The patient is explaining a religious practice that influences the patient's culture. The
nurse needs to support this practice by offering other food sources for the patient to
consume which can provide the same or similar nutrients as the foods that are being
abstained. Stating that religious practices do not need to be followed while pregnant is
not taking the patient's cultural needs into consideration. Stating that avoiding milk and
dairy products will harm the fetus is an inappropriate scare tactic to persuade the patient
to follow the nurse's cultural expectations. Stating that the patient has will power has no
value and should not be made by the nurse.
12. The nurse is visiting a patient from a nondominant culture that was recently discharged
from the hospital for complications of pregnancy. Which outcome of care would be
appropriate for this patient?
A) The patient will return to normal activities of daily living.
B) The patient will understand signs of the complication developing again.
C) The patient will consult with cultural healers to ensure the complication does not
occur again.
D) The patient will follow medical advice and keep all scheduled appointments for
continued care.
Ans: B
Feedback:
Because the patient is from a nondominant culture, the best outcome of care would be
for the patient to understand the signs of the complication developing again so that
medical treatment can be obtained as soon as possible. An outcome that the patient will
return to normal activities of daily living may not be appropriate because of the
complication. The patient may consult with cultural healers about the complication, but
it is unclear if the complication can be treated by them. Expecting the patient to follow
medical advice and keep all scheduled appointments does not necessarily take the
patient's cultural needs into consideration.
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13. During an assessment, a pregnant patient tells the nurse that “white foods” are not
consumed in the patient's culture. What should the nurse do first after learning this
information?
A) Ask the patient to define “white foods.”
B) Document that “white foods” are not eaten.
C) Explain that “white foods” have nutrients needed for pregnancy.
D) Discuss reasons why “white foods” are avoided in the patient's culture.
Ans: A
Feedback:
The patient is from a culture that avoids eating “white foods.” The first thing that the
nurse should do is assess what “white foods” are. From this information, the nurse could
then determine appropriate diet teaching for the patient. The nurse needs to do more
than document that “white foods” are avoided. The nurse needs to know what “white
foods” are before explaining their nutritional value. Discussing why “white foods” are
avoided demonstrates cultural insensitivity.
14. A patient from a nondominant culture is in the second stage of labor and is not
demonstrating any manifestations of pain. What should the nurse do to support this
patient?
A) Offer to provide the patient with a back rub
B) Measure the pain level with a pain rating scale
C) Discuss pain control measures with the physician
D) Nothing until the patient asks for pain medication
Ans: B
Feedback:
The patient may be from a culture where it is inappropriate to respond to pain. The
nurse needs to objectively assess the patient's level of pain before implementing
nonpharmacologic or pharmacologic pain management measures. Offering to provide a
back rub may or may not be desired by the patient. Discussing pain control measures
with the physician may be premature. Doing nothing unless the patient asks for pain
medication is inappropriate, considering the patient is in the second stage of labor.
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15. A pregnant patient from a nondominant culture wants to deliver the baby “the American
way” with epidural pain management. How should the nurse describe this patient's
statement about childbirth?
A) Attempting assimilation
B) Combating ethnocentrism
C) Expression of acculturation
D) Stereotyping American behavior
Ans: A
Feedback:
Assimilation occurs when people from a nondominant culture adopt the values of the
dominant culture. The patient believes that epidural pain management is the American
way of childbirth. Ethnocentrism is the belief one's own culture is superior to all others.
The patient is not demonstrating ethnocentrism. Acculturation is losing ethnic traditions
because of disuse. There is no enough information to determine if the patient is
practicing acculturation. Stereotyping is expecting a person to act in a characteristic way
without regard to individual traits. The patient's desire to deliver the baby the American
way is not stereotyping.
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Chapter 4 Home Care and the Childbearing and Childrearing Family
1. Which observation indicates to the nurse that a family is not functioning in a healthy
way?
A) The family pays cash for health care.
B) The father comforts his crying daughter.
C) The mother states, “This family couldn't function without me.”
D) The father does not share his concerns so his wife will not worry about them.
Ans: D
Feedback:
Health family functioning includes communication with each other and identifying and
sharing feelings about the home situation. The family paying cash for health care does
not support a family that is not functioning in a healthy way. The father comforting his
crying daughter demonstrates healthy family functioning. The mother who believes the
family could not function without could be a statement of frustration or evidence that
the family needs her to maintain healthy functioning.
2. During a home visit, the nurse determines that a family is functioning in a healthy
manner. Which behavior did the nurse observe to make this determination?
A) A mother is angry that the father never helps with housework.
B) A brother is so jealous of his new sister that he hides her clothes.
C) A father wishes the family was able to spend more time together.
D) A mother states she has grown up since giving birth to her children.
Ans: D
Feedback:
A family that is supportive of all family members and provides an environment
conducive to each member's continued growth and development is more likely to be
able to manage home care. The mother's statement about growing up after giving birth
demonstrates growth. The mother that is angry because of no help with housework is
demonstrating unrealistic expectations of family members. A brother that hides clothes
is not successfully dealing with the stresses within the family. The father wishing the
family had more time together might be overwhelmed with the home situation.
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3. A pregnant patient experiencing exacerbation of asthma is prescribed home care. The
nurse is planning to assess the patient's community for resources. On which areas will
the nurse focus this assessment? (Select all that apply.)
A) Religion
B) Age span
C) Health care
D) Recreation
E) Environment
Ans: C, E
Feedback:
For a patient with asthma, the community areas that the nurse should assess include
environment and access to health care. The environment could exacerbate the patient's
symptoms and health care could influence the patient's ability to obtain help if
necessary. Religion, age span, and recreation will not necessarily impact the
maintenance of the patient's asthma.
4. The nurse is completing the health histories for twin toddlers. Which statement should
the nurse make to the mother that focuses on the 2020 National Health Goals?
A) Discuss adequate dental care.
B) Explain the need for the toddlers to have socialization with other children.
C) Remind the mother that the toddlers need regularly scheduled vaccinations.
D) Stress the importance of home safety and prevention of accidental poisoning.
Ans: C
Feedback:
The 2020 National Health Goal applicable to this situation is to reduce or eliminate
vaccine-preventable diseases such as measles, pertussis, and varicella. Dental care,
socialization, and home safety are not 2020 National Health Goals.
5. A preschooler, receiving home oxygen therapy, is excited about an upcoming birthday.
Which statement by the patient's mother indicates that additional teaching on the safety
of home oxygen therapy is needed for the occasion?
A) “I'll be careful that no guest smokes.”
B) “I'll be certain he doesn't get too tired.”
C) “His brother can help him open presents.”
D) “I'm baking a cake and we'll have candles.”
Ans: D
Feedback:
During the home visit, the nurse should have instructed the mother on home safety with
oxygen therapy. This includes knowing not to light candles near oxygen for a birthday.
The statement about no guests smoking indicates that teaching has been effective. The
statements about fatigue and having help with presents do not evaluate the effectiveness
of teaching on home oxygen safety.
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6. During a home care visit, the nurse learns that a pregnant adolescent is concerned about
being lonely at home. What should the nurse suggest to help with this problem?
A) The family could buy her a television set.
B) Her father could purchase her a cell phone.
C) The family might install an intercom system.
D) The family could have dinner together in the same room.
Ans: D
Feedback:
To combat the feelings of loneliness and support the family structure, the family can
plan to have one meal a day together, such as dinner, in the same room. A cell phone,
intercom system, or television set may or may not help the adolescent with feelings of
loneliness.
7. The nurse is assessing a patient for potential home care. Which patient statement
indicates that the patient will be able to take a medication that is prescribed for three
times a day?
A) “I can take the three pills together at one time.”
B) “I will take one pill before breakfast, before lunch, and before dinner.”
C) “I can take one pill when I have symptoms and save the others for later.”
D) “I will take the pill when I get up in the morning and before I go to bed.”
Ans: B
Feedback:
The nurse is assessing if a patient is able to properly take a medication that is prescribed
three doses per day. The statement that the patient will take one dose before breakfast,
lunch, and dinner is evidence that the patient will be able to safely take the medication.
Taking three pills together, taking a pill with symptoms, and taking a pill in the morning
and at night indicates that the patient will not be able to adhere to the prescribed
medication schedule.
8. A parent caring for an ill child at home states that at first it was difficult but now has
adjusted to the situation. Which would be the most appropriate nursing diagnosis for this
family?
A) Hopelessness related to prolonged home care
B) Health-seeking behaviors related to home care
C) Readiness for enhanced coping related to home care
D) Compromised coping related to difficulty of home care
Ans: C
Feedback:
Home care of a child can place a heavy burden on a family as the stress of being
responsible for an ill child's daily health status can have a negative impact on a parent's
self-esteem. The statement that the mother has adjusted to the situation indicates
readiness for enhanced coping. The mother is not demonstrating hopelessness,
health-seeking behaviors, or compromised coping.
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9. The nurse is explaining to a school-age child the need to soak the hands twice a day to
help with an infection. Which teaching should the nurse provide that would be
appropriate for the patient's cognitive level?
A) “You should soak both hands to get them clean.”
B) “You need to stay in bed while your hand soaks.”
C) “Would you like to sit in the chair or stay in bed to soak your hand?”
D) “I know your favorite show is on right now, but we need to soak your hand now.”
Ans: C
Feedback:
Before anyone can be cared for at home, teaching will be required so the family
understands the illness and principles of care. Because the patient is a school-age child,
the nurse should provide choices so that the patient has a sense of control over the
situation. Soaking both hands may or may not be medically necessary. Telling the
patient to stay in bed or soaking the hands now does not provide the patient with a sense
of control and may lead to resistance or nonadherence to medical treatment.
10. A patient who is at 30 weeks gestation is prescribed bed rest and home care. Which
skills should the nurse anticipate providing when making the home care visits with the
patient? (Select all that apply.)
A) Health teaching
B) Monitoring vital signs
C) Bathing and washing hair
D) Monitoring fetal heart rate
E) Administering medication
Ans: A, B, D, E
Feedback:
Nursing care is considered skilled home nursing care if it includes primary health care
provider–prescribed procedures such as dressing changes, administration of medication,
health teaching, or observation of a woman status through monitoring vital signs or fetal
heart rate. Bathing and washing hair is not considered skilled nursing care.
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11. The nurse is preparing to obtain a health history from a patient with preeclampsia who is
at home. In which area should the nurse conduct the assessment?
A) Bedroom, where it is quiet and private
B) Kitchen, so other family members can participate
C) Porch, so the nurse does not have to enter the home
D) Living room, so as to not interrupt television viewing
Ans: A
Feedback:
The nurse should provide privacy and confidentiality when obtaining the health history
and performing a physical examination. The nurse should identify a private location
such as the bedroom. The kitchen, porch, and living room are not private areas for this
assessment.
12. The nurse instructs a patient who is at 28 weeks gestation on the correct use of the fetal
heart monitor at home. Which observation indicates that teaching has been effective?
A) The device is sitting on the kitchen table.
B) The patient cannot locate the device during a routine home visit.
C) The patient has two rhythm strips to share with the nurse during the home visit.
D) The patient has a log with the date, time, and number of fetal heart beats counted.
Ans: D
Feedback:
Fetal heart rate monitoring can be taught to the patient including how to record the
findings. The patient that has a log with the date, time, and number of fetal heart beats
counted indicates that teaching has been effective. Fetal heart monitoring should be
conducted in the reclining position and the device should not be on the kitchen table.
The patient who is unable to locate the device is not performing the assessment as
instructed. The patient who has two rhythm strips to share with the nurse may or may
not be performing the assessment as instructed.
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13. The nurse instructs a pregnant patient who is at home on bed rest to drink at least eight
glasses of fluid each day. What would be the best method to encourage the patient to
drink this amount?
A) Get up every hour and get a drink from the refrigerator.
B) Keep a pitcher of fluid readily available on a bedside table.
C) Drink cool liquids and avoid hot liquids because they increase thirst.
D) Drink the eight glasses before the spouse leaves for work in the morning.
Ans: B
Feedback:
All women during pregnancy should drink six to eight full glasses of fluid a day to
obtain adequate fluid for effective kidney function and placental exchange. The patient
on bed rest should have a supply of fluid close to the bed such as a water pitcher so this
can be done easily. Getting up every hour does not support bed rest. Drinking eight
glasses of fluid before the spouse leaves for work does not ensure adequate hydration
during the day. The temperature of the liquids is inconsequential. Hot liquids do not
necessarily increase thirst.
14. The nurse is preparing to make a home visit to admit a new patient to services. Which
actions should the nurse take to ensure personal safety? (Select all that apply.)
A) Keeping the car doors unlocked
B) Keeping the gas tank of the car full
C) Parking the car in a well-lighted area
D) Using a map to avoid getting lost in a strange neighborhood
E) Informing the agency of the estimated arrival time and expected return
Ans: B, C, D, E
Feedback:
Safety tips for making home care visits include keeping the gas tank full, park in a
well-lighted area, using a map to avoid getting lost, and informing the agency of the
estimated arrival time and expected return. The nurse should keep the car doors locked
for safety.
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15. During a home visit, the nurse begins teaching on medication safety in the home. What
should the nurse include in these instructions? (Select all that apply.)
A) Never take medication in front of children.
B) Use a reminder sheet and cross off when a medication has been taken.
C) Drink a full glass of water with pills to ensure they reach the stomach.
D) Keep all medication in a safe place above the height for a child to reach.
E) Place medication doses in empty candy or mint containers to reduce waste.
Ans: A, B, C, D
Feedback:
Instructions for medication safety in the home should include never taking medication in
front of children, using a reminder sheet to keep track of medication doses, drinking a
full glass of water with medication doses, and keeping all medication in a safe place
above the height for a child to reach. Medications should not be placed in empty candy
or mint containers because children might think that these items are candy and might
accidentally ingest someone else's prescribed medication. This could lead to an
accidental poisoning in the home.
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Chapter 5 The Nursing Role in Reproductive and Sexual Health
1. After an examination, a pregnant patient is diagnosed with a cystocele. How should the
nurse explain this finding to the patient?
A) A fold of peritoneum behind the uterus
B) Pouching of the bladder into the vaginal wall
C) A part of the rectum is pushing into the vaginal wall.
D) Folds of peritoneum that cover the uterus front and back
Ans: B
Feedback:
Pouching of the bladder into the vaginal wall is a cystocele. A fold of peritoneum
behind the uterus is posterior ligament. A part of the rectum pushing into the vaginal
wall is a rectocele. Folds of peritoneum that cover the uterus front and back are the
broad ligaments.
2. A pregnant patient is concerned about a sharp pain that is felt in the lower abdomen
when making a quick move. What action should the nurse take to help this patient?
A) Assess when the patient's last bowel movement occurred.
B) Explain that the sharp pain is tension on a uterine ligament.
C) Notify the physician because of manifestations of appendicitis.
D) Instruct that the pain is a pulled muscle and a heating pad will help.
Ans: B
Feedback:
If a pregnant woman moves quickly, she may pull one of the round or broad ligaments
causing a quick, sharp pain of frightening intensity in one of the lower abdominal
quadrants. This pain is not associated with bowel function. Pain of this type calls for
conscientious assessment or it can be mistaken for labor or appendicitis pain. This pain
is not because of a pulled muscle and application of heat is not indicated.
3. After an assessment, a pregnant patient asks the nurse questions about her changing
uterus and body. Which nursing diagnosis would be appropriate for the patient at this
time?
A) Anxiety related to being pregnant
B) Ineffective coping related to being pregnant
C) Health-seeking behaviors related to reproductive functioning
D) Disturbance in body image related to body changes with pregnancy
Ans: C
Feedback:
The patient is asking questions related to reproductive functioning which indicates
health-seeking behaviors. The patient's questions do not indicate that the patient is
experiencing anxiety, ineffective coping, or a disturbance in body image.
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4. The nurse is planning expected outcomes for a female patient who will be celebrating
her 40th birthday in a few months. Which outcome would be appropriate for this
patient?
A) Patient will follow safer sex practices.
B) Patient will explain the process of reproduction.
C) Patient will perform breast self-examination every 2 months.
D) Patient will schedule a mammogram shortly after 40th birthday.
Ans: D
Feedback:
To help patients better understand reproductive functioning and sexual health
throughout their life, an expected outcome might include encouraging women over 40 to
have mammograms. The process of reproduction would be appropriate for younger
patients. Teaching on safer sex practices would be appropriate for an adolescent. Breast
self-examinations should be conducted every month.
5. A patient is diagnosed with a uterus that is slightly retroverted. When discussing the
implications of this finding, what should the nurse include?
A) This finding indicates the need for surgery.
B) This finding will render the patient infertile.
C) This finding should not cause fertility issues.
D) This finding could interfere with conception.
Ans: C
Feedback:
A retroverted uterus means the uterus tips back. Minor variations of these positions do
not tend to cause reproductive problems. A retroverted uterus does not mean that the
patient needs surgery. A retroverted uterus does not interfere with fertility. The only
way that a retroverted uterus will interfere with conception is if the abnormal position is
extreme because the sharp bend can block the deposition or migration of sperm.
6. A patient sustains a vaginal tear during the labor and delivery process and is
experiencing profuse vaginal bleeding. What should the nurse instruct the patient about
this injury?
A) This injury will heal rapidly.
B) Surgery is needed to repair the tear.
C) Future vaginal deliveries will be compromised.
D) Bleeding will continue for several weeks to months.
Ans: A
Feedback:
The blood supply to the vagina is furnished by the vaginal artery, a branch of the
internal iliac artery. Vaginal tears at childbirth tend to bleed profusely because of this
rich blood supply. The same rich blood supply is the reason any vaginal trauma at birth
heals rapidly. Surgery is not needed to repair the tear. Future vaginal deliveries will not
be compromised. Bleeding will not continue for several weeks to months.
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7. An adolescent female patient asks the nurse questions about menstruation. What should
the nurse include when instructing the patient?
A) Keeping active increases discomfort.
B) A prostaglandin inhibitor best relieves pain.
C) Eating sour foods contributes to discomfort.
D) Hair permanents do not take during a menstrual flow.
Ans: B
Feedback:
Prostaglandin inhibitors such as ibuprofen (Motrin) are most effective for menstrual
pain because they reduce inflammation as well as relieve pain. Activity reduces the
discomfort of menstrual pain. Eating sour foods does not influence menstruation.
Menstruation does not affect hair care needs.
8. The nurse is preparing instruction about the menstrual cycle for adolescent patients.
What will the nurse include about changes in the uterine endometrium during the second
half of the cycle?
A) It is corkscrew-like because of progesterone stimulation.
B) It is thick and purple-hued because of estrogen stimulation.
C) It is thin and transparent because of progesterone stimulation.
D) It is twisted and ragged because of follicle-stimulating hormone.
Ans: A
Feedback:
During the second half of the menstrual cycle, the formation of progesterone in the
corpus luteum causes the glands of the uterine endometrium to become corkscrew or
twisted in appearance and dilated. The uterine endometrium is thin and transparent
immediately after the end of the menstrual cycle. The uterine endometrium does not
become thick and purple in color because of estrogen stimulation. The uterine
endometrium does not become twisted and ragged because of follicle-stimulating
hormone.
9. The nurse completes an assessment of an adolescent patient's menstrual pattern. Which
finding should the nurse identify as being within normal limits?
A) The usual cycle is 19 days.
B) Flow usually lasts 4 to 6 days.
C) Menstruation started at age 10 years.
D) The average amount of flow is 500 ml.
Ans: B
Feedback:
The duration of menstrual flow averages between 4 and 6 days. The average menstrual
cycle is 28 days. The average age at onset of menstruation is 12.4 years. The average
amount of flow is 30 to 80 ml per menstrual period.
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10. The nurse is preparing an educational session about menstruation for a group of
adolescents. Which hormone should the nurse instruct as initiating ovulation?
A) Estrogen
B) Progesterone
C) Luteinizing hormone
D) Follicle-stimulating hormone
Ans: C
Feedback:
Luteinizing hormone is responsible for ovulation or release of the mature egg cell from
the ovary. Estrogen, progesterone, and follicle-stimulating hormone are not hormones
responsible for initiating ovulation.
11. The nurse is determining the topics to include in an educational program to meet the
2020 National Health Goals for sexuality and reproductive health. What should the
nurse include when planning this program? (Select all that apply.)
A) Outline safer sex practices.
B) Discuss the disadvantages of annual mammography.
C) Review skills to use to negate unwanted sexual advances.
D) Stress the importance of abstinence when teaching adolescent patients.
E) Explain the advantages of obtaining the human papillomavirus vaccination.
Ans: A, C, D, E
Feedback:
The nurse can help the nation achieve the 2020 National Health Goals for sexuality and
reproductive health by outlining safer sex practices, reviewing refusal skills, teaching
about abstinence, and explaining the advantages of obtaining the human papillomavirus
vaccination. Annual mammography is not a disadvantage for women of a specific age
range.
12. The nurse is determining a patient's gender role. What is the nurse doing to make this
determination?
A) Assessing the patient's sexual preferences
B) Asking what gender the patient identifies with
C) Analyzing the patient's chromosomal inheritance
D) Analyzing the patient's demonstrated sexual behaviors
Ans: D
Feedback:
Gender role is the male or female behavior a person exhibits which may or may not be
the same as biologic gender or gender identity. Assessing the patient's sexual
preferences, asking what gender the patient identifies, and analyzing the patient's
chromosomal inheritance will not determine the patient's gender role.
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13. A patient with vaginismus has attended counseling to treat the disorder. Which patient
statement indicates that treatment has been effective?
A) “Lacking an interest in sex is a normal part of aging.”
B) “I can learn to tolerate sex if I want to have a family.”
C) “I can use lubricants to help with the pain of having sex.”
D) “Sex is not a bad thing but can be enjoyed with my husband.”
Ans: D
Feedback:
Vaginismus is involuntary contraction of the muscles at the outlet of the vagina when
coitus is attempted that prohibits penile penetration and may occur in women who have
been raped. Other causes are unknown, but it could also be the result of early learning
patterns in which sexual relations were viewed as bad or sinful. As with other sexual
problems, sexual or psychological counseling to reduce this response may be necessary.
A lack of interest in sex is not a normal part of aging. Learning to tolerate sex and using
lubricants does not help with the problem of vaginismus.
14. The nurse is planning an education seminar on safer sexual practices for a group of
young adults. Which information should the nurse include in this teaching? (Select all
that apply.)
A) Use a latex condom for intercourse.
B) Void immediately after having sex.
C) Avoid sex with intravenous drug users.
D) Hand-to-genital sex is the safest sexual practice.
E) Inspect your sexual partner for lesions in the genital area.
Ans: A, B, C, E
Feedback:
Safer sexual practices include using a latex condom for intercourse, voiding
immediately after having sex, avoiding sex with intravenous drug users, and inspecting
the sexual partner for genital lesions. Hand-to-genital sex is not the safest sexual
practice. Abstinence is the only 100% guarantee against not contracting a sexually
transmitted infection.
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15. The nurse is teaching a male patient about sildenafil citrate (Viagra) prescribed for
erectile dysfunction. Which patient statement indicates that teaching has been effective?
A) “A change in vision is to be expected.”
B) “This medication is birth control for men.”
C) “I can take this medication several times a day.”
D) “I should report to my health care provider an erection that lasts longer than 4
hours.”
Ans: D
Feedback:
An erection lasting more than 4 hours can occur when taking sildenafil citrate (Viagra).
This condition can lead to penile tissue damage and should be reported to a health care
provider. A change in vision should be reported to the health care provider. Sildenafil
citrate (Viagra) is not birth control. This medication should be taken up to one dose per
day.
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Chapter 6 Nursing Care for the Family in Need of Reproductive Life Planning
1. For which patient assessment finding would an intrauterine device (IUD) be
contraindicated?
A) Misshapen uterus
B) Multiple sexual partners
C) Diagnosis of hypertension
D) History of thromboembolic disease
Ans: A
Feedback:
Use of an IUD may be contraindicated for a woman whose uterus is distorted in shape
because the device might perforate the uterine wall. The device is not contraindicated
for multiple sexual partners, hypertension, or history of thromboembolic disease.
Infection is no longer a concern because the vaginal string no longer conducts fluid. The
device does not impact hormone levels and will not influence blood pressure or blood
flow.
2. A male patient is considering a vasectomy. Which information should the nurse instruct
the patient about this procedure? (Select all that apply.)
A) Sexual intercourse can resume in a week.
B) The procedure can be done as an outpatient.
C) An opioid analgesic will be prescribed for pain control.
D) Use a birth control method until a negative sperm reports occur.
E) Spermatozoa present in the vas deferens will be viable for 2 weeks.
Ans: A, B, D
Feedback:
After a vasectomy, sexual intercourse can resume after 1 week. The procedure can be
completed as an outpatient. The patient may experience a small amount of local pain
afterward, which can be managed by taking a mild analgesic and applying ice to the site.
An additional birth control method should be used until two negative sperm reports at
about 6 and 10 weeks have been obtained. Spermatozoa, which were present in the vas
deferens at the time of surgery, can remain viable for as long as 6 months.
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3. A patient comes into the family planning clinic and requests a prescription for birth
control pills. Which assessment finding indicates that an ovulation suppressant would
not be the best contraceptive method for the patient?
A) Age 30 years
B) Allergy to foreign protein
C) Irregular menstrual cycles
D) History of thromboembolism
Ans: D
Feedback:
Combination oral contraceptives are not routinely prescribed for patient with a history
of thromboembolic disease. The patients' age would not be a contraindication for this
type of contraceptive. An allergy to foreign protein would impact the patient's ability to
use condoms. Irregular menstrual cycles would be an indication for combination oral
contraceptives.
4. A female patient has forgotten to take an ovulation suppressant for two mornings in a
row. What should the nurse advise the patient to do?
A) Take two pills a day for the rest of the month.
B) Take three pills immediately and avoid coitus for the remainder of the month.
C) Start a new cycle of 21 pills immediately plus additional estrogen for the next 3
days.
D) Take two pills now and use a second method of contraception for the remainder of
the month.
Ans: D
Feedback:
If two consecutive active pills are missed, the patient should be advised to take two pills
immediately. Then the patient should continue the following day with the usual
schedule. Missing two pills may allow ovulation to occur, so an added contraceptive
such as a spermicide should be used for the remainder of the month. The patient does
not need to take two pills every day for the rest of the month, take three pills and abstain
from coitus, or start a new cycle of 21 pills.
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5. The nurse is planning an educational session on contraceptives for a group of adolescent
high school students. What does the nurse need to do when planning this session?
A) Argue that encouraging abstinence is unrealistic during the teenage years.
B) Discuss that the application of a condom should occur after penile-vulvar contact.
C) Explain that the combination oral contraceptive approach is the best for
adolescents.
D) Teaching about contraceptive options while avoiding indirect encouragement of
sexual activity.
Ans: D
Feedback:
The nurse can help the nation achieve the 2020 National Health Goals by teaching
adolescents about contraceptive options while being cautious to avoid indirectly
encouraging sexual activity among teens. A 2020 National Health Goal is to increase the
number of adolescents being instructed on abstinence. A condom should be applied
before penile-vulvar contact. Oral contraceptives are not the contraceptive of choice for
adolescents.
6. The nurse is teaching a patient on the use of a diaphragm for contraception. Which
patient statement indicates that instruction has been not been effective?
A) “I need to use my finger to remove the diaphragm.”
B) “I should remove the diaphragm 6 hours after intercourse.”
C) “I should stop using a diaphragm if I get an infection of my cervix.”
D) “I need to have the diaphragm checked if my weight changes by 30 lb.”
Ans: D
Feedback:
The patient should be instructed to have the size of the diaphragm checked if weight
changes by 15 lb. The patient does need to use the finger to remove the diaphragm. The
diaphragm should be removed 6 hours after intercourse. The diaphragm should not be
used if the patient is experiencing a cervical infection.
7. A 40-year-old woman who smokes desires a reliable contraceptive method. Which
should the nurse recommend to this patient?
A) An ovulation suppressant
B) A condom and spermicide
C) A spermicidal suppository
D) The rhythm (calendar) method
Ans: B
Feedback:
Women who are 40 years of age and smoke should not take ovulation suppressants.
Irregular menstrual cycles make natural methods difficult. Women older than the age of
40 may have vaginal dryness, so a spermicidal suppository would not be effective. The
best option is for the patient to use a condom and spermicide.
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8. An adolescent female who has recently started menstruating asks for a highly reliable
birth control method. Which method should the nurse discuss with the patient?
A) Postcoital douching
B) An intrauterine device
C) An ovulation suppressant
D) Vaginal foam for her and a condom for her partner
Ans: D
Feedback:
For many adolescent couples, use of a dual method, such as a vaginally inserted
spermicide by the girl and a condom by her partner, is a preferred method of birth
control. Postcoital douching is not a method of birth control. Intrauterine devices are
rarely used for early adolescents because the uterus may still be small. Ovulation
suppressants are not recommended until a female has been menstruating for at least 2
years.
9. A patient wants to calculate fertile days using the calendar method. What will the nurse
instruct the patient to subtract when making this calculation?
A) 14 from 28
B) 18 from the shortest period and 11 from the longest
C) 18 from the longest period and 11 from the shortest
D) The length of the average period from the ideal of 28
Ans: B
Feedback:
To calculate “safe” days, the patient should subtract 18 from the shortest cycle. This
number predicts the first fertile day. Then subtract 11 from the longest cycle. This
represents the last fertile day. The other calculations are incorrect to determine fertile
days.
10. The nurse instructs a patient on cervical mucus changes that occur during ovulation.
Which statement indicates that teaching has been effective?
A) “During ovulation, the mucus is thick.”
B) “Ovulation makes the mucus more acidic.”
C) “The mucus is white because of more white blood cells.”
D) “When the mucus is thin and watery, then ovulation is occurring.”
Ans: D
Feedback:
On the day of ovulation, the cervical mucus becomes copious, thin, watery, and
transparent. During ovulation, the mucus is not thick, not acidic, and not white.
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11. The nurse is planning instruction for a patient desiring to have a tubal ligation. Which
information should the nurse emphasize when teaching the patient?
A) She must think of the procedure as irreversible.
B) The procedure will reduce her menstrual flow in amount.
C) She should schedule it to be done just before a menstrual flow.
D) She will have lessened dysmenorrhea following the procedure.
Ans: A
Feedback:
People considering tubal ligation should think of this procedure as permanent before
having it done. Although reversal of the procedure can be done, the success rate is
between 70% and 80%. Tubal ligation does not alter the menstrual flow or affect
dysmenorrhea. Ectopic pregnancy could result if it is done following ovulation.
12. A patient asks the nurse if a cervical cap is better than a diaphragm for contraception.
What should explain as the advantages of a cervical cap?
A) No initial fitting is required.
B) It can be left in place longer.
C) It needs no spermicidal jelly.
D) It does not need to be refitted after pregnancy.
Ans: B
Feedback:
Caps can be kept in place longer—up to 48 hours—because they do not put pressure on
the vaginal walls or urethra. A fitting is needed for a cervical cap. They are used with
spermicidal jelly, and they do need to be refitted after pregnancy.
13. The nurse instructs a patient on the use of a vaginal estrogen/progestin rings (NuvaRing)
for contraception. Which patient statement indicates that additional instruction is
needed?
A) “I am to take the ring out overnight.”
B) “I will leave the ring in place for 3 weeks.”
C) “I leave the ring in place during intercourse.”
D) “I am to use other birth control if I take the ring out for 4 hours.”
Ans: A
Feedback:
If the ring is removed for 4 hours for any purpose, it should be replaced with a new ring
and a form of barrier protection is to be used for the next 7 days. The ring is not
removed overnight. The ring is left in place for 3 weeks and then removed for
menstruation during the ring-free week. The ring does not need to be removed for
intercourse.
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14. When should the nurse instruct a female patient using the basal body temperature
method of contraception to refrain from having sexual intercourse?
A) Four days after noticing a temperature rise
B) Fourteen days after the last day of the menstrual period
C) Three days after recording a slight drop in temperature followed by an increase
D) Three to 4 days after recording a slight increase followed by a dip in the
temperature
Ans: C
Feedback:
As soon as a woman notices a slight dip in temperature followed by an increase that
lasts for at least 72 hours, this indicates that ovulation has occurred. The patient should
not be instructed to refrain from sexual intercourse 4 days after a temperature rise, 14
days after the last menstrual period, or 3 to 4 days after a slight increase followed by a
dip in the temperature.
15. The nurse completes instructing a patient on the use of the contraceptive patch. Which
patient response indicates that teaching has been effective?
A) The patch is immediately effective after application.
B) The patch should be applied to the breasts, hips, or back.
C) The patch should be applied to the abdomen, buttocks, or back.
D) The patch should be covered when swimming because of chlorine's effect on the
adhesive.
Ans: C
Feedback:
The patch should be applied only to the buttocks, back, abdomen, or torso and never on
the breasts. The patch is safe for wearing during swimming and bathing. The patch
requires application for 1 week before becoming effective.
16. A patient who has unprotected intercourse has obtained the morning after pill but has
not yet taken the prescribed dosage. What nursing diagnosis should the nurse identify as
appropriate for the patient at this time?
A) Powerlessness
B) Spiritual distress
C) Decisional conflict
D) Readiness for enhanced knowledge
Ans: C
Feedback:
The patient has the morning after pill but has not yet taken the prescribed dosage. This
indicates that the patient has not yet made a decision. Powerlessness would be
applicable if the patient's planned contraceptive was ineffective. Spiritual distress would
be appropriate if there were a conflict regarding contraceptive methods. Readiness for
enhanced knowledge would be applicable if the patient was asking about different
contraceptive types.
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17. An Rh-negative patient of 6 weeks gestation is scheduled for a medically induced
termination. Which outcomes should the nurse identify as appropriate for this patient?
(Select all that apply.)
A) Attended contraceptive counseling
B) Received Rho (D) immune globulin
C) Scheduled postprocedure sonogram
D) Avoided strenuous activity for 3 weeks
E) Experienced menstrual cycle in 2 months
Ans: A, B, C
Feedback:
A medically induced termination should be performed within 63 days of gestation. Once
the termination medication has been provided, the patient should receive Rho (D)
immune globulin, schedule a postprocedure sonogram, and attend contraceptive
counseling. The patient should avoid strenuous activity for 3 days and have a return of a
menstrual cycle within 2 to 4 weeks.
18. A patient recovering from a surgical pregnancy termination returns for a postprocedure
examination. The patient tells the nurse that she is relieved that the procedure is over
however is feeling sad. What should the nurse do to assist the patient at this time?
A) Suggest the patient talk with a counselor.
B) Ask the patient to identify the source of the sadness.
C) Recommend the patient attend contraceptive counseling sessions.
D) Discuss the need for an antidepressant with the health care provider.
Ans: A
Feedback:
After a surgical pregnancy termination, most women report to be relieved with the
decision; however, those who express sadness and guilt may need to be referred for
professional counseling so they can integrate and accept this event in their lives. Asking
the patient to identify the source of the sadness will not help the patient work through
feelings caused by the procedure. Recommending the patient attend contraceptive
counseling sessions does not focus on the source of the patient's sadness. Discussing
antidepressant use may be premature for this patient.
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19. A patient received a scheduled dose of depot medroxyprogesterone acetate (DMPA) 6
weeks ago. Today, the patient reports that a regular menstrual cycle is 2 weeks late.
What is the first thing that should be done for this patient?
A) Perform a pregnancy test.
B) Provide prenatal counseling.
C) Discuss pregnancy termination options.
D) Explain side effects of the contraceptive.
Ans: A
Feedback:
Because the patient is receiving a contraceptive that could cause amenorrhea, and the
patient's menstrual cycle is 2 weeks late, the first thing that should be done is a
pregnancy test to determine if the patient is pregnant. The results of this test will
determine the next course of action. Depot medroxyprogesterone acetate (DMPA) is a
pregnancy category X medication, which means it should not be administered to
someone who is pregnant. It is unclear if the patient was already pregnant when the last
dose was provided 6 weeks prior to the current situation. It is premature to provide
prenatal counseling. Depending on the results of the pregnancy test, the nurse may need
to explain side effects of the contraceptive which include amenorrhea.
20. A postpartum patient asks the nurse when the subdermal hormone implant for
contraception can be inserted. What should the nurse respond to this patient?
A) In 6 weeks
B) In 1 month
C) 1 week after your next menstrual cycle
D) Before being discharged after this delivery
Ans: A
Feedback:
The subdermal hormone implant can be placed 6 weeks after the birth of a baby. One
month is too soon for the implant to be placed after the birth of a baby. Typically, the
rod is inserted during menses or no later than day 7 of a menstrual cycle to be certain
that the patient is not pregnant at the time of insertion. The implant will not be placed
immediately after the delivery of a baby.
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Chapter 7 Nursing Care of the Family Having Difficulty Conceiving a Child
1. A female patient learns that she is the carrier of the X-linked recessive disease
hemophilia A. Her spouse is free of the disease. What should the nurse teach the patient
about the frequency of this disease in future children?
A) All male children will inherit it.
B) All female children will be carriers like she is.
C) All male children will have a 50% risk to inherit the disease.
D) All female children will have a 50% risk to inherit the disease.
Ans: C
Feedback:
In X-linked recessive diseases such as hemophilia A, females who inherit the affected
gene will be heterozygous, and, because a normal gene is also present, the expression of
the disease will be blocked. But because males have only one X chromosome, the
disease will be manifested in any male children who receive the affected gene from their
mother. If the mother has the affected gene on one of her X chromosomes and the father
is disease free, the chances are 50% a male child will manifest the disease and 50% a
female child will carry the disease gene. All male children will not inherit the disease.
All female children will not be a carrier of the disease. Females will not inherit the
disease.
2. A married couple is beginning genetic counseling. What should the nurse instruct the
couple regarding expectations from this process? (Select all that apply.)
A) The results will be provided to the couple only.
B) The results will be provided as quickly as possible.
C) The married couple makes the decision to participate in the process.
D) Medically recommended procedures will be immediately scheduled.
E) The married couple will sign informed consent forms for procedures.
Ans: A, B, C, E
Feedback:
Legal responsibilities of genetic testing, counseling, and therapy include the results will
not be withheld and given to the persons directly involved; the results will be provided
as quickly as possible; participation in genetic screening is elective; and those desiring
genetic screening must sign an informed consent for the procedures. After genetic
counseling, persons are not to be coerced to undergo procedures; therefore, medically
recommended procedures will not be immediately scheduled.
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3. Both people in a married couple carry the recessive gene for cystic fibrosis. When asked
about the incidence of any children developing the disorder, what should the nurse
respond?
A) “There is no chance.”
B) “There is a 1 in 4 chance.”
C) “There is a 2 in 4 chance.”
D) “There is a 3 in 4 chance.”
Ans: B
Feedback:
In autosomal recessive inheritance, the disease will not occur unless both parents have
recessive genes for the disorder. There is a 25% chance a child born to the couple will
be disease and carrier free; a 50% chance the child will be, like the parents, free of
disease but carrying the unexpressed disease gene; and a 25% chance the child will have
the disease, or a 1 in 4 chance. With the recessive gene carried by both parents, the
chances of children developing the disease are not 2 in 4, 3 in 4, or 0 in 4.
4. The nurse is visiting a family who has a child with a genetic disorder. The oldest
daughter in the family is planning marriage within the next few months. Which
intervention should the nurse include that would support the 2020 National Health Goals
for genetic disease?
A) Counsel the daughter to have no children.
B) Encourage the daughter to have genetic counseling.
C) Discuss voluntary sterilization options prior to marriage.
D) Explain that the chance of genetic anomalies in children is slim.
Ans: B
Feedback:
To support the 2020 National Health Goals for genetic anomalies, the nurses can help
achieve these goals by being sensitive to the need for and educating parents about
genetic screening in preconceptual settings. This means that the nurse should encourage
the daughter to have genetic counseling. It is outside of the nurse's scope of practice to
counsel the daughter to remain childless or undergo voluntary sterilization. The nurse
would not know the daughter's chances of having a child with a genetic disorder unless
genetic testing is performed.
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5. A pregnant patient has been counseled to have an amniocentesis. For which genetic
conditions should the nurse instruct the patient that this diagnostic test will detect?
A) Impetigo
B) Trisomy 21
C) Diabetes mellitus
D) Phenylketonuria
Ans: B
Feedback:
Trisomy 21 or Down syndrome is the most common genetic disorder that can be
detected through examination of amniotic fluid obtained through amniocentesis.
Impetigo, diabetes mellitus, and phenylketonuria cannot be diagnosed through
examination of amniotic fluid.
6. The nurse is making a home visit to a family with a child born with a genetic
abnormality. Which observation in the home indicates to the nurse that the parents are
adjusting to the newborn's health problems?
A) The father walks by the bassinet.
B) The father leaves during the visit.
C) The mother holds the baby during the visit.
D) The mother sits on the sofa while the baby cries.
Ans: C
Feedback:
Evidence that the parents are adjusting to the newborn with the genetic abnormality is
the mother holding the baby during the visit. The father walking by the bassinet or
leaving during the visit does not indicate adjustment. The mother sitting on the sofa
while the baby cries does not indicate that the mother is adjusting to the newborn's
health problems.
7. A young married woman says that she is planning a tubal ligation because mental
retardation runs in her husband's family and she does not want any children with this
problem. Which nursing diagnosis would best apply to this couple?
A) Anxiety related to marital issues
B) Deficient knowledge of genetically inherited disorders
C) Spiritual distress related to inappropriate approach to the issue of having children
D) Sexual dysfunction related to the possibility of having a cognitively impaired
child
Ans: B
Feedback:
The young woman is making a decision to not have children without having information
about her husband's family and the people who have mental retardation. This is a
knowledge deficit and is the most appropriate diagnosis for this couple. This situation
does not support the diagnoses of anxiety, spiritual distress, or sexual dysfunction.
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8. After an assessment, a couple planning marriage decides to schedule an appointment for
genetic counseling in several months. Which information from the assessment would
support this couple's decision? (Select all that apply.)
A) The male and female are second cousins.
B) The male has a friend who has hemophilia.
C) The female has a foster brother with sickle-cell anemia.
D) The male and female are both of Mediterranean descent.
E) The female's sister gave birth to a baby with Down syndrome.
Ans: A, D, E
Feedback:
Couples who are most apt to benefit from a referral for genetic testing or counseling
include a closely related couple, are of ethnic backgrounds in which specific illnesses
are known to occur, and those whose close relatives have a child with a genetic disorder.
Having a friend with hemophilia and a foster brother with sickle-cell anemia would not
support the couple's decision to have genetic counseling.
9. A patient becomes concerned upon learning for the need to have a karyotype performed.
What should the nurse explain to this patient about this test? (Select all that apply.)
A) It photographs and displays chromosomes.
B) It is procedure done on all pregnant women.
C) It reveals diseases present on chromosomes.
D) It can only be done during the first trimester of pregnancy.
E) It guarantees that a fetus will not be ill from a genetic disorder.
Ans: A, C
Feedback:
A karyotype photographs and displays chromosomes and is done to reveal diseases on
chromosomes only. A karyotype is not performed on all pregnant women, but only
those in which a genetic anomaly is suspected. The karyotype can be performed at any
time during gestation and does not guarantee that a fetus will not be ill from a genetic
disorder.
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10. The nurse is beginning an assessment to determine a couple's chances of having
offspring with genetic anomalies. What should the nurse include in this assessment?
(Select all that apply.)
A) Age of the female member of the couple
B) Diseases in the family that span three generations
C) Ethnic background of both members of the couple
D) Minimal expression of a previously undiagnosed disorder
E) Employment status of the male member of the couple
Ans: A, B, C, D
Feedback:
When conducting a health history assessment in anticipation of genetic counseling, the
nurse will assess the age of the female member of the couple because some genetic
anomalies are more common in older female patients. The nurse will also assess the
couple for diseases that span three generations in both of the families and will assess the
couple's individual ethnic backgrounds. Physical assessment can identify minimal
expression of a disorder that has gone previously undiagnosed. Employment status is
not typically a part of the health history in preparation for genetic counseling.
11. During an assessment, the nurse suspects a newborn has a chromosomal disorder. What
did the nurse most likely assess in the baby?
A) Short neck
B) Bowed legs
C) Low-set ears
D) Slanting of the palpebral fissure
Ans: C
Feedback:
Ears that are low-set ears is a common assessment finding in newborns with the trisomy
chromosome abnormalities. Short neck, bowed legs, and slanting of the palpebral fissure
are less common findings in a newborn with a chromosomal disorder.
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12. A pregnant patient learns that her fetus has a genetic anomaly that will affect cognitive
and musculoskeletal development. The patient is meeting with her spouse and the nurse
and wants to know what options are available to them. What is the first thing that the
nurse needs to do to help this couple with decision making?
A) Suggest routes to terminate pregnancy.
B) Assist the couple in identifying their values.
C) Analyze the opinions of extended family members.
D) Explain health care options for the baby going forward.
Ans: B
Feedback:
A useful place to start counseling is with values clarification to be certain a couple
understands what is most important to them. Routes to terminate the pregnancy should
be the last option. Analyzing the opinions of extended family members should occur
after the couple identifies their own values. Explaining health care options for the baby
going forward can occur after the couple identifies their values.
13. A child is diagnosed with an X-linked dominant inheritance disorder. What should the
nurse explain to the parents about this disorder?
A) It only affects male offspring.
B) It appears in every generation.
C) All children of the couple will be affected.
D) Diseases caused by this disorder are not life threatening.
Ans: B
Feedback:
X-linked dominant inheritance disorders appear in every generation. The pattern of
inheritance is through the X chromosome and affects female offspring. All children will
not be affected. It is unclear if the diseases caused by this disorder are life threatening.
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14. What should the nurse include when counseling potential parents about genetic
disorders?
A) Environmental influences may affect multifactorial inheritance.
B) Genetic disorders primarily follow Mendelian laws of inheritance.
C) All genetic disorders involve a similar number of abnormal chromosomes.
D) The absence of genetic disorders in both families eliminates the possibility of
having a child with a genetic disorder.
Ans: A
Feedback:
Not all genetic disorders follow Mendelian laws of inheritance. Diseases caused by
multiple factors do not follow Mendelian laws because more than a single gene or HLA
is involved. Environmental influences may be instrumental in determining whether the
disorder is expressed. All genetic disorders do not involve a similar number of abnormal
chromosomes. A family history may reveal no set pattern so an absence of genetic
disorders in both families does not necessarily eliminate the possibility of having a child
with a genetic disorder.
15. The results of a pregnant patient's quadruple screen were positive, and an amniocentesis
was performed. The amniocentesis report states no genetic anomalies present. What
should the nurse do to assist this patient understand the test results?
A) Reassure that the report of the amniocentesis is valid.
B) Suggest that additional testing be performed on the fetus.
C) Explain that most of quadruple screens are falsely positive.
D) Remind that 30% of amniocentesis screens are falsely positive.
Ans: A
Feedback:
Receiving a false-positive report is unfortunate because it can potentially interfere with
the mother's bonding with her infant. Women may need some “debriefing” time after
false-positive reports and may need to be reassured several times that the report of a
possible chromosomal deviation was not true. The patient does not need additional
testing done on the fetus. It is documented that 30% of quadruple screens are falsely
positive. It is not true that 30% of amniocentesis screens are falsely positive.
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Chapter 8 The Nursing Role in Genetic Assessment and Counseling
1. A couple, in which both members are 22 years of age, wants to know what it can do to
improve the chances of conceiving. What should the nurse respond to this couple?
A) Have coitus every day.
B) Have coitus every other day.
C) Consume a high-fat, low-protein diet.
D) The female-superior position is the best for conception.
Ans: B
Feedback:
Although frequent intercourse may stimulate sperm production, men need sperm
recovery time after ejaculation to maintain an adequate sperm count. This is why coitus
every other day, rather than every day, during the fertile period will probably yield
faster results. A diet that is low in fat and moderate in protein is recommended. The
male-superior position is the best for conception because the sperm will be closer to the
cervical opening.
2. The nurse is assessing a male for sperm count. Which circumstance would be most
important to ask about during the health history?
A) Jogs frequently
B) Works at a desk job
C) Eats a low-lipid diet
D) Takes a vitamin supplement
Ans: B
Feedback:
Actions that directly increase scrotal heat, such as working at a desk job, may cause
sperm counts to be lower compared with men whose occupations allow them to be
ambulatory at least part of each day. Jogging, a low-lipid diet, and vitamin
supplementation are not as important as physical posturing when beginning an analysis
for a low sperm count.
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3. The nurse is planning an education session for couples planning to conceive. What
should the nurse include to support the 2020 National Health Goals? (Select all that
apply.)
A) Highlight the importance of good nutrition.
B) Include health promotion activities for both men and women.
C) Stress the importance of having coitus every day while trying to conceive.
D) Remind about safe sex practices to reduce sexually transmitted infections.
E) Explain that conception rarely occurs in couples during the first year of trying.
Ans: A, B, D
Feedback:
To support the 2020 National Health Goals, the nurse should focus on health promotion,
early identification of problems that could lead to subfertility such as poor nutrition, and
teaching patients about safer sex practices so the incidence of sexually transmitted
infections and pelvic inflammatory disease can be reduced. It is best to have coitus
every other day so that the sperm have adequate time to mature. Ninety percent of
couples who have routine unprotected sex conceive within a year.
4. A male is diagnosed as being infertile, but he wants to have children with his spouse.
Which response should the nurse provide to this patient?
A) “You need to consider donor-alternative insemination.”
B) “The chance of conception is slight with artificial insemination.”
C) “You and your sexual partner should consider embryo transfer first because it is
safer.”
D) “Artificial insemination is useful only if your sexual partner has an allergy to your
sperm.”
Ans: A
Feedback:
Donor sperm (alternative insemination by donor) is used if the man has no sperm. There
is no evidence to support that the chance of conception is slight with artificial
insemination. Embryo transfer is for the female partner who does not produce ova.
Artificial insemination is useful for many different situations.
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5. The nurse is teaching a female to take her basal body temperature daily to assess the
time of ovulation. What will the patient's body temperature reflect as the day of
ovulation?
A) Increase a degree.
B) Decrease a degree.
C) Fluctuate a degree daily.
D) Spike one degree then drop.
Ans: A
Feedback:
At the time of ovulation, the basal body temperature can be seen to dip slightly (about
0.5ºF); it then rises to a level no higher than normal body temperature; it then stays at
that level until 3 or 4 days before the next menstrual flow. This increase in basal body
temperature marks the time of ovulation because it occurs immediately after ovulation.
Upon ovulation, the basal body temperature will not decrease a degree, fluctuate, or
spike and then drop.
6. The nurse is scheduling a female patient for a hysterosalpingogram. Which question
would be most important to ask the patient before scheduling the procedure?
A) When did you have coitus last?
B) Are you allergic to any sedatives?
C) What is your blood type and Rh factor?
D) When do you expect your next menstrual flow?
Ans: D
Feedback:
Because X-ray, which might be harmful to a growing pregnancy, is used, the procedure
must be scheduled immediately following a menstrual flow when pregnancy could not
be present. Asking about coitus, sedative allergies, or blood time and Rh factor are not
the most important when scheduling the patient for a hysterosalpingogram.
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7. The female partner of a young couple is concerned about what the results of fertility
tests might reveal. Which nursing diagnosis should the nurse use to plan care for this
patient?
A) Fear related to possible outcome of subfertility studies
B) Deficient knowledge related to measures to promote fertility
C) Anxiety related to the procedures necessary for fertility testing
D) Situational low self-esteem related to the apparent inability to conceive
Ans: A
Feedback:
The nursing diagnosis that would be the most appropriate to address concerns about the
outcome of subfertility studies would be fear related to possible outcome. There is no
information to support this patient having a knowledge deficit. The patient already had
the testing so anxiety regarding these procedure processes would not be appropriate at
this time. It is unknown if the patient will experience situational low self-esteem
because the results of the fertility tests have not be disclosed to the patient.
8. The nurse instructs a couple on the process of basic fertility testing. Which patient
statements indicate that teaching has been effective? (Select all that apply.)
A) “The quality of the sperm will be looked at.”
B) “The sperm will be tested for adequate number.”
C) “A test will be done to determine if ovulation is occurring.”
D) “The importance of using in vitro fertilization will be discussed.”
E) “It will be determined if the sperm and eggs are able to meet correctly.”
Ans: A, B, C, E
Feedback:
There are three parts to basic fertility testing. The sperm are analyzed for number and
quality, ovulation is determined, and the environment for the sperm and egg to meet is
analyzed. In vitro fertilization is not a part of basic fertility testing.
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9. What should the nurse include when explaining endometriosis as a cause for a female
patient's infertility?
A) “You do not ovulate because of endometrial implants on the ovaries.”
B) “Your uterine cervix fails to close because it is engorged with tissue.”
C) “Menstrual sloughing does not occur, so there is never a new base for embryo
growth.”
D) “Ovulation does take place misplaced endometrial tissue interferes with transport
of the ovum.”
Ans: D
Feedback:
Endometriosis refers to the implantation of uterine endometrium, or nodules, that have
spread from the interior of the uterus to locations outside the uterus. If viable particles of
endometrium enter a tube, they can cause tubal obstruction; growths on the ovaries can
displace fallopian tubes away from the ovaries, preventing the entrance of ova into the
tubes. Peritoneal macrophages, which are drawn to nodules of endometrium, can destroy
sperm. Endometriosis does not affect ovulation, cervix competence, or menstruation.
10. Before signing the consent form for a myomectomy, the patient asks why an intrauterine
device (IUD) is being inserted because the goal is to become pregnant. What should the
nurse respond to the patient?
A) After a myomectomy, an IUD will not prevent pregnancy.
B) Pregnancy must be avoided for a year after a myomectomy.
C) It is used to ensure an adequate menstrual blood flow occurs.
D) It prevents the uterine sides from touching and forming new adhesions.
Ans: D
Feedback:
During a myomectomy, an IUD may be inserted to prevent the uterine sides from
touching and forming new adhesions. This treatment can be difficult for a woman to
accept because preventing pregnancy through an IUD is exactly what she does not want
to do. The IUD is not inserted to prevent pregnancy. An IUD will prevent pregnancy
even after a myomectomy. The IUD is not used to ensure an adequate menstrual blood
flow.
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11. The nurse completes instructing a female patient on the process of in vitro fertilization.
Which statement indicates that patient teaching has been effective?
A) “I will need to select a surrogate mother.”
B) “It can be done with frozen donor sperm.”
C) “Most procedures are effective the first time tried.”
D) “This is dangerous if there is ovarian cancer in my family.”
Ans: B
Feedback:
Fresh or frozen sperm can be used for in vitro fertilization. A surrogate mother is not
needed for this procedure. Often, more than one attempt is needed before successful
implantation occurs. The success of in vitro fertilization is not related to the incidence of
ovarian cancer in the family.
12. The nurse has completed a fertility assessment on a couple and is preparing outcomes
for care. Which statement indicates that the couple wants to continue with the process,
regardless of the outcome?
A) Couple interested in learning about other options to having a family.
B) Couple wants to have a family but has limited resources for artificial methods.
C) Couple states the desire to minimize disruptions in their normal activities for
testing.
D) Couple desires to continue with testing after it is determined that one partner is
fertile.
Ans: D
Feedback:
The outcome statement that indicates the couple wants to continue with the process
would be “couple desires to continue with testing after it is determined that one partner
is fertile.” The interest in learning about other options, having limited resources, and
minimizing disruptions do not indicate that the couple desires to continue with testing.
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13. A female patient is willing to alter nutrition and activity status in an attempt to conceive.
What teaching should the nurse provide to support this patient's desire? (Select all that
apply.)
A) Exercise 30 minutes each day.
B) Plan to reduce body fat to less than 10%.
C) Ingest vegetables that are high in fiber.
D) Consciously reduce every day stressors.
E) Add brown rice and dark bread to the diet.
Ans: A, C, D, E
Feedback:
Nutrition, body weight, and exercise are all important for adequate ova production
because they all influence the blood glucose/insulin balance. The patient should be
instructed to exercise 30 minutes each day, ingest vegetables that are high in fiber, and
reduce every day stressors. In addition, eating slowly digested carbohydrate foods such
as brown rice and dark bread rather than food such as white bread, which has easily
digested carbohydrates, cannot only increase fertility by keeping insulin levels balanced.
Decreased body weight or a body/fat ratio of less than 10% can reduce pituitary
hormones such as FSH and LH and halt ovulation.
14. A female patient being treated for infertility is completing the third course of
clomiphene citrate (Clomid). What information should the nurse prepare for the patient
in the event this course does not result in conception?
A) Agencies that coordinate adoptions
B) Strategies to improve sperm motility
C) Additional options to achieve conception
D) Informed consent for taking a fourth course of the medication
Ans: C
Feedback:
Clomiphene citrate (Clomid) has a 5-day initial course. Then two additional courses of 5
days each can be provided. If the last course does not result in conception, the nurse
should prepare additional options to achieve conception. It is premature to begin
discussing adoption with the patient. Sperm motility is not an issue at this time. There is
no need for informed consent for a fourth course of the medication.
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15. An adolescent is diagnosed with pelvic inflammatory disease believed to have been
caused by abdominal adhesions after an appendectomy. What should the nurse explain
to the patient about future success with fertility?
A) “You won't ovulate normally.”
B) “Your body will reject any embryo implantation.”
C) “Your cervical mucus is changed, and sperm will be killed.”
D) “The eggs won't go through the fallopian tubes because of scarring.”
Ans: D
Feedback:
Pelvic inflammatory disease could result from a ruptured appendix or from abdominal
surgery that left adhesions in the tubes. About 12% of those who acquire PID will be
left subfertile because of tubal scarring. Pelvic inflammatory disease does not affect
ovulation. It will not cause the rejection of embryo transplantation, and it does not
change the cervical mucus.
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Chapter 9 Nursing Care During Normal Pregnancy and Care of the Developing Fetus
1. The nurse is explaining the process of fertilization to a patient who has just learned of
being pregnant. On which day during pregnancy should the nurse explain that the
embryo implants on the uterine surface?
A) Four days after fertilization
B) Eight to 10 days after fertilization
C) The 14th day of a “typical” menstrual cycle
D) Ten days after the start of the menstrual flow
Ans: B
Feedback:
Implantation, or contact between the growing structure and the uterine endometrium,
occurs approximately 8 to 10 days after fertilization. Four days after fertilization the
structure is a zygote. Implantation does not occur on the 14th day of a typical menstrual
cycle or 10 days after the start of a menstrual flow.
2. A patient who learns of being 9 weeks pregnant asks the nurse to explain the changes
that are occurring with her body. Which nursing diagnosis should the nurse identify as
being appropriate for the patient at this time?
A) Anxiety
B) Impaired coping
C) Deficient knowledge
D) Readiness for enhanced knowledge
Ans: D
Feedback:
The patient asks the nurse to explain the changes that are occurring, which indicates that
the patient is ready for more information or enhanced knowledge. Deficient knowledge
would be appropriate if the patient where participating in some action or activity that
would be harmful and would need information to correct that action. The patient's
request for more information is not consistent with the diagnoses of anxiety or impaired
coping.
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3. The nurse is teaching a patient in the first trimester of pregnancy about the importance
of folic acid in the diet and how folic acid supplements might be beneficial. For which
reason is the nurse teaching the patient about this vitamin?
A) Maintains energy throughout the pregnancy
B) Controls the risk of hypertension while pregnant
C) Prevents neural tube disorders in the developing fetus
D) Sustains a slow and steady weight gain while pregnant
Ans: C
Feedback:
Folic acid deficiency in pregnancy can lead to midline closure defects such neural tube
disorders. One of the 2020 National Health Goals addresses an adequate folic acid
intake while pregnant, and the nurse can help the nation achieve this goal by urging
women to have an optimum folic acid level. Folic acid is not encouraged in the pregnant
patient to maintain energy, control the risk of hypertension, or sustain a slow and steady
weight gain while pregnant.
4. A pregnant patient asks why an -fetoprotein serum level has been ordered. What
should the nurse explain to the patient about this test?
A) It screens for placenta function.
B) It measures the fetal liver function.
C) It may reveal chromosomal abnormalities.
D) It tests the ability of the patient's heart to accommodate the pregnancy.
Ans: C
Feedback:
-Fetoprotein (AFP) is a substance produced by the fetal liver that can be found in both
amniotic fluid and maternal serum. The level is abnormally high if the fetus has an open
spinal or abdominal wall defect because the open defect allows more AFP to enter the
mother's circulation. Although the reason is unclear, the level is low if the fetus has a
chromosomal defect such as Down syndrome. Between 85% and 90% of neural tube
anomalies, and 80% of Down syndrome babies can be detected by this method. The
-fetoprotein level is not used to screen for placenta functioning, measure fetal liver
function, or test the ability of the patient's heart to accommodate the pregnancy.
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5. The nurse teaches the importance of avoiding nonessential substances to a young adult
female who is 6 weeks pregnant. Which patient statement indicates that teaching has
been effective?
A) “I can drink on weekends only.”
B) “Smoking is bad for me and my baby.”
C) “Smoking is permitted as long as I do it outdoors.”
D) “Only one beer or one glass of wine is permitted while pregnant.”
Ans: B
Feedback:
Because almost all drugs are able to cross into the fetal circulation, it is important that a
woman take no nonessential drugs, including alcohol and nicotine, during pregnancy.
Alcohol perfuses across the placenta and can cause fetal alcohol sequence disorders.
Because it is difficult to tell what quantity is “safe,” pregnant women are advised to
drink no alcohol during pregnancy. The statement that “smoking is bad for me and my
baby” indicates that teaching has been effective. The patient should be instructed to
avoid all alcohol intakes while pregnant and to not smoke.
6. The nurse is completing a physical assessment with a patient who has just learned of
being pregnant. The patient's last menstrual period was August 15. When should the
nurse instruct the patient that the baby will be due?
A) July 15
B) June 22
C) May 22
D) April 15
Ans: C
Feedback:
When using Naegele's rule, the nurse should count backward 3 calendar months from
the first day of the patient's last menstrual period and then add 7 days. For August 15,
the month would be May and the day would be 15 plus 7 or 22. May 22 is when the
patient's baby is due. July 15, June 22, and April 15 are inappropriate applications of
Naegele's rule.
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7. A patient who is 28 weeks pregnant is demonstrating signs of placental insufficiency.
The health care provider prescribes betamethasone. What should the nurse inform the
patient regarding the purpose of this medication?
A) It stops premature labor.
B) It improves functioning of the placenta.
C) It potentiates the formation of surfactant.
D) It improves immunologic function of the fetus.
Ans: C
Feedback:
Synthetically increasing steroid levels in the fetus through the use of betamethasone can
hurry alveolar maturation and surfactant production without interfering with permanent
lung function prior to a preterm birth. Surfactant is formed and excreted by the alveolar
cells of the lungs at about the 24th week of pregnancy, decreases alveolar surface
tension on expiration, prevents alveolar collapse, and improves the infant's ability to
maintain respirations in the outside environment at birth. Betamethasone is not being
given to this patient to stop premature labor, improve the function of the placenta, or
improve immunologic function of the fetus.
8. During a physical assessment, the nurse palpates a pregnant patient's fundus at the level
of the umbilicus. What statement should the nurse make to the patient about this
assessment finding?
A) “You are at 12 weeks of your pregnancy.”
B) “You are at 20 weeks of your pregnancy.”
C) “You are at 36 weeks of your pregnancy.”
D) “You can go into labor at any time now.”
Ans: B
Feedback:
As a fetus grows, the uterus expands to accommodate its size. Typical fundal
measurements are over the symphysis pubis at 12 weeks, at the umbilicus at 20 weeks,
and at the xiphoid process at 36 weeks. The patient is not going to go into labor at any
time.
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9. The nurse is planning to instruct a patient who is 12 weeks pregnant on interventions to
stop smoking. What should the nurse include in these instructions? (Select all that
apply.)
A) Purchase nicotine chewing gum.
B) Follow a smoking cessation plan.
C) Ask a friend to help with smoking cessation actions.
D) Apply a nicotine patch when the cravings become severe.
E) Ask the physician if a smoking cessation medication can be used.
Ans: B, C, E
Feedback:
Interventions to help a pregnant patient with smoking cessation include following a
smoking cessation plan, asking a friend to help with smoking cessation actions, and
asking the physician if a smoking cessation medication can be used. The patient should
not be instructed to purchase nicotine chewing gum or a patch because nicotine is a
pregnancy category C drug, will cross into the placenta, and adversely affect the
developing fetus.
10. A pregnant patient is scheduled for an abdominal ultrasound. What should the nurse
instruct the patient about this procedure?
A) Avoid drinking fluid 1 hour prior to the procedure.
B) Expect to have a catheter inserted prior to the procedure.
C) Empty the bladder 1 hour and just prior to the start of the procedure.
D) Drink a glass of water every 15 minutes starting 90 minutes before the procedure.
Ans: D
Feedback:
The sound waves reflect best if the uterus can be held stable so it is helpful if the woman
has a full bladder at the time of the procedure. To ensure this, ask her to drink a full
glass of water every 15 minutes beginning 90 minutes before the procedure and not void
until after the procedure. The patient will not have a catheter inserted for this procedure.
The patient should not avoid fluids 1 hour prior to the procedure. The bladder should not
be emptied until the procedure concludes.
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11. A pregnant patient scheduled for an amniocentesis asks the nurse how the placenta is
not punctured during the procedure. What should the nurse respond to the patient?
A) “A uterus feels soft over the placenta site.”
B) “A sonogram to locate it will be done first.”
C) “It would not be harmful even if it were punctured.”
D) “Placentas always form on the posterior uterine wall.”
Ans: B
Feedback:
After the patient is placed in the supine position, a sonogram is done to determine the
position of the fetus, the location of a pocket of amniotic fluid, and the placenta. The
uterus does not feel soft over the placenta site. It would be harmful if the placenta were
punctured during the procedure. Placentas do not always form on the posterior uterine
wall.
12. A pregnant patient is concerned that the baby is going to drown in the uterus because of
the fluid. What should the nurse respond about fetal respiration?
A) “You are breathing for the baby.”
B) “The baby's breathing is very minor until delivery.”
C) “The baby's lungs can accommodate all of the fluid.”
D) “Oxygen is provided to the baby through the placenta.”
Ans: D
Feedback:
Fetal circulation differs from extrauterine circulation because the fetus derives oxygen
and excretes carbon dioxide not from gas exchange in the lung but from exchange in the
placenta. The baby's lungs are not functioning in utero so the response that the baby's
breathing is very minor until delivery and the baby's lungs being able to accommodate
the fluid are incorrect. The patient is not “breathing for the baby.”
13. A pregnant patient is directed to perform a daily fetal movement count. What should the
nurse instruct the patient about this count? (Select all that apply.)
A) Lie down to do the count after eating a meal.
B) Count only movements that are strong enough to hurt.
C) Report if no movement is felt for any half-hour period.
D) Choose a different time frame each day to count movements.
E) Count fetal movements until a total of 10 are counted and record the time.
Ans: A, E
Feedback:
A healthy fetus moves at about 10 times per hour. The nurse should instruct the patient
to lie in a left recumbent position after a meal, observe and record the number of fetal
movements or kicks the fetus makes until 10 movements are counted, and record the
time. If an hour passes without 10 movements, the patient should walk around a little
and try a count again. If 10 movements cannot be felt in a second 1-hour period, the
patient should telephone the primary health care provider.
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14. The nurse determines that a fetal nonstress test is nonreactive for over 20 minutes. What
does the nurse realize as being reasons for this finding? (Select all that apply.)
A) The patient is sleeping.
B) The patient is hypoglycemic.
C) The patient is using an illicit drug.
D) The patient is exercising too much.
E) The patient is smoking while pregnant.
Ans: B, C, E
Feedback:
Reasons for lessened variability during a fetal nonstress test include maternal smoking,
drug use, or hypoglycemia. Lessened variability does not occur because the patient is
sleeping or because the patient is exercising too much.
15. The nurse is evaluating the fetal heart rate rhythm strip and determines that the
amplitude varies with a rate 15 to 20 beats/min. What does this assessment finding
indicate to the nurse about variability?
A) Variability is absent.
B) Variability is minimal.
C) Variability is normal.
D) Variability is marked.
Ans: C
Feedback:
Variability is absent when there is no peak-to-trough range detected. Variability is
minimal when an amplitude range is detected but the rate is 5 beat/min or fewer.
Variability is moderate or normal when an amplitude range is detected and the rate is 6
to 25 beat/min. Variability is marked when an amplitude range is detected and the rate is
greater than 25 beat/min.
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Chapter 10 Nursing Care Related to Psychological and Physiologic Changes of Pregnancy
1. A pregnant patient tells the nurse that she is not happy to learn about the pregnancy. At
which point in the pregnancy does the nurse realize that the patient will change her mind
about the pregnancy?
A) Around the third month
B) After the seventh month
C) When quickening occurs
D) After lightening happens
Ans: C
Feedback:
Quickening or feeling the baby move inside the body is a dramatic event and causes the
pregnant woman's feelings about the pregnancy to change. Quickening occurs during
the second trimester of the pregnancy, which is after the third but before the seventh
month. Lightening occurs near the end of the pregnancy.
2. The nurse determines that a pregnant patient is working through developmental tasks.
Which statement did the patient make to the nurse?
A) “My mother and I are closer than ever before.”
B) “I'm thinking about everything I eat these days.”
C) “There are a lot of allergies in my husband's family.”
D) “I don't care what sex baby I have as long as it's healthy.”
Ans: A
Feedback:
For the first time in her life, a woman during pregnancy can begin to empathize with the
way her mother used to worry. This can make her own mother become more important
to her and a new, more equal relationship develops. Thinking about diet, allergies, and
the baby's sex are not developmental tasks for the pregnant patient.
3. A newly wed young adult patient tells the nurse that she hopes to become pregnant
soon. What should the nurse recommend to this patient to support the 2020 National
Health Goals for pregnancy? (Select all that apply.)
A) Stop smoking.
B) Increase exercise.
C) Eat a healthy diet.
D) Reduce work hours.
E) Limit alcohol intake.
Ans: A, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for pregnancy by
being certain women receive counseling in nutrition and low uses of alcohol and
tobacco before pregnancy so they can enter intended pregnancies in the best health
possible. Increasing exercise and reducing work hours are not interventions that would
support the 2020 National Health Goals for pregnancy.
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4. The nurse is planning to instruct a patient who is 6 weeks pregnant about increasing the
intake of milk each day. Which statement should the nurse make as the most effective
health teaching measure?
A) “The fetus needs milk to build strong bones and teeth.”
B) “Your future baby will benefit from a high milk intake.”
C) “Milk is a rich source of calcium that is important for fetal growth.”
D) “Milk will strengthen your fingernails as well as be good for the baby.”
Ans: D
Feedback:
There is a tendency to organize health instructions during pregnancy around the baby;
however, this approach may be inappropriate early in pregnancy, before the fetus stirs,
and before a woman is convinced not only she is pregnant but also there is a baby inside
her. At early stages, a woman may be much more interested in doing things for herself
because it is her body, her tiredness, and her well-being that will be directly affected.
The nurse should instruct the patient to drink more milk to improve fingernail strength.
The statements that address fetal development are inappropriate for the nurse to use for
health teaching at this time.
5. The spouse of a pregnant patient is quiet during prenatal visits but is demonstrating
emotional involvement in the pregnancy. What action did the spouse perform?
A) States he definitely wants a girl
B) Refuses to paint the baby's room blue
C) States he is concerned about the loss of his free time
D) Walks around furniture as if his abdomen is enlarged
Ans: D
Feedback:
Many men experience physical symptoms and may begin to gain weight along with
their partner. As a woman's abdomen begins to grow, the partner may perceive himself
as growing larger too, as if he were the one who was experiencing changing boundaries
the same as his partner. This indicates emotional involvement in the pregnancy. Stating
a specific sex for the baby, losing free time, and refusing to paint the baby's room blue
are not indications that the spouse is emotionally involved in the pregnancy.
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6. A father is preparing a 4-year-old son for the arrival of a new baby. Which statement
should the nurse suggest the father use to explain this to the child?
A) “Mother will need to spend a lot of time with the new baby.”
B) “It will be fun to have a sister or brother to give your old toys to.”
C) “The new baby will need your bed so we're buying you a new one.”
D) “A new baby will make our family bigger but not change our love for you.”
Ans: D
Feedback:
Preschool-age children may need to be assured periodically during pregnancy a new
baby will be an addition to the family and will not replace them in their parents'
affection. Explaining that the mother will have less time for the child, equating the new
baby as “fun,” and taking away a bed for the baby will not help the child accept the new
baby into the family.
7. A patient makes an appointment at the prenatal clinic because she thinks she might be
pregnant. Which assessment is a probable sign of pregnancy?
A) Amenorrhea
B) Enlargement and darkening of areola
C) Nausea and vomiting
D) A positive pregnancy test
Ans: D
Feedback:
A probable sign of pregnancy is one that is objective and can be measured by an
observer. A positive pregnancy test is a probable sign of pregnancy. Amenorrhea,
enlargement and darkening of areola, and nausea and vomiting are presumptive signs
because they could indicate another health condition.
8. After an examination, an advanced practice nurse confirms that a patient is pregnant.
What did the nurse assess in this patient? (Select all that apply.)
A) Painful breast tissue
B) Positive pregnancy test
C) Fetal movements felt by the nurse
D) Visualization of the fetus by ultrasound
E) Fetal heart rate separate from the patient's
Ans: C, D, E
Feedback:
There are only three documented or positive signs of pregnancy—demonstration of a
fetal heart separate from the mother's, fetal movements felt by an examiner, and
visualization of the fetus by ultrasound. Painful breast tissue is a presumptive sign of
pregnancy. A positive pregnancy test is a probably sign of pregnancy.
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9. The nurse is assessing a patient who is 3 months pregnant. Which breast changes would
the nurse expect to assess in this patient?
A) Enlarged lymph nodes
B) Slack, soft breast tissue
C) Deeply fissured nipples
D) Darkened breast areolae
Ans: D
Feedback:
As the pregnancy progresses, the areola of the nipples darkens, and its diameter
increases. Enlarged lymph nodes; slack, soft breast tissue; and deeply fissured nipples
are not expected breast changes in a pregnant patient.
10. After a routine examination, a patient tells the nurse that she plans to use a home
pregnancy test to determine if she is pregnant. What should the nurse respond to this
patient's plan?
A) Use a diluted urine specimen.
B) Arrange for prenatal care if the test is positive.
C) Wait until after two missed menstrual periods.
D) Refrain from eating for 4 hours before testing.
Ans: B
Feedback:
After a positive pregnancy test, the first step should be to arrange for prenatal care. This
is the response that the nurse should make to the patient. The urine is not usually diluted
for a home pregnancy test. The patient should not wait for 2 months before determining
if she is pregnant. Eating does not impact the results of the home pregnancy test.
11. A patient who is 2 months pregnant is concerned about frequent urination. What should
the nurse instruct the patient about this occurrence?
A) This means urine is more concentrated.
B) The fetus is adding urine to the patient's bladder.
C) It is caused by pressure on the bladder from the uterus.
D) There is a decrease in the glomerular cells of the kidney.
Ans: C
Feedback:
A pregnant woman may notice an increase in urinary frequency during the first 3
months of pregnancy, until the uterus rises out of the pelvis and relieves pressure on the
bladder. An increase in urination early in pregnancy is not caused by concentrated urine
or a decrease in the glomerular cells of the kidney. The fetus is not adding urine to the
patient's bladder.
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12. A patient who is 16 weeks pregnant has a lower blood pressure than that of
prepregnancy levels. What should the nurse realize as being the cause for this lower
blood pressure?
A) Prepregnancy blood pressure measurements were inaccurate.
B) Blood pressure progressively decreases throughout the entire pregnancy.
C) A decrease in the second trimester may occur because of placental growth.
D) Dehydration because blood pressure increases steadily throughout pregnancy.
Ans: C
Feedback:
In some women, blood pressure actually decreases slightly during the second trimester
because the expanding placenta causes peripheral resistance to circulation to lower. The
lower blood pressure is not because prepregnancy blood pressure measurements were
inaccurate. Blood pressure does not normally decrease throughout the entire pregnancy.
There is no enough information to determine if the patient is dehydrated; however, this
is not the reason for the blood pressure to be lower in the second trimester of pregnancy.
13. A pregnant patient who has frequent allergic responses to drugs is concerned about an
allergic reaction to the fetus. What information will the nurse use when responding to
this patient's concern?
A) Immunologic activity is decreased during pregnancy.
B) The level of aldosterone during pregnancy reduces production of IgG antibodies.
C) The kidneys release a hormone during pregnancy to prevent this from happening.
D) The decreased corticosteroid activity during pregnancy ensures this will not
happen.
Ans: A
Feedback:
Immunologic competency during pregnancy decreases probably to prevent a woman's
body from rejecting the fetus as if it were a transplanted organ. Aldosterone does not
impact the production of IgG antibodies. The kidneys do not influence an allergic
response. Adrenal gland activity increases during pregnancy.
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14. During a routine prenatal examination, a pregnant patient's urine is found to have a trace
amount of glucose. What does this finding indicate to the nurse?
A) The patient has gestational diabetes.
B) Lactose may be spilling into the urine.
C) The patient is eating excessive calories.
D) It is because of a decrease in glomerular filtration rate.
Ans: B
Feedback:
Because reabsorption of glucose by the tubule cells occurs at a fixed rate, this causes
some accidental spilling of glucose into the urine during pregnancy. Lactose, which is
being produced by the mammary glands but is not used during pregnancy, will also be
spilled into the urine. If more than a trace amount of glucose is found in the pregnant
patient's urine, this could indicate gestational diabetes. The increase of glucose in the
urine is not because of eating excessive calories. The glomerular filtration rate increases
in pregnancy.
15. During an assessment, a patient who is 5 months pregnant tells the nurse that she has to
change her diet because she is just becoming too fat. Which nursing diagnosis should
the nurse use to guide interventions for the patient at this time?
A) Powerlessness
B) Imbalanced nutrition
C) Deficient knowledge
D) Disturbed body image
Ans: D
Feedback:
The diagnosis of disturbed body image is the most appropriate because the patient is
equating the weight gain of pregnancy as being fat. The patient may or may not have a
knowledge deficit. There is no evidence to support the diagnosis of imbalanced
nutrition. There is also no evidence to support that the patient is experiencing
powerlessness.
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16. The nurse is concerned that a pregnant patient is not adjusting emotionally to being
pregnant. Which statement indicates that the patient may need additional counseling?
A) “I cannot wait to lose all of this excess weight.”
B) “I need to get right back to work after delivery.”
C) “My mother has been so helpful during this time.”
D) “My dad has already purchased toys for the baby!”
Ans: B
Feedback:
The statement that the patient needs to get back to work after delivery could indicate
that the patient feels the pregnancy is robbing her of financial stability or ruin chances
of a promotion. Desiring to lose weight after pregnancy does not indicate that the patient
is not adjusting emotionally to being pregnant. The statements about parental support do
not indicate that the patient is not adjusting emotionally to being pregnant.
17. The nurse instructs a pregnant patient on the need to increase foods containing folic
acid. Which patient statement indicates that teaching has been effective?
A) “Eating an extra orange a day is important.”
B) “I need to drink two glasses of milk each day.”
C) “I will add spinach to my salad every evening.”
D) “Cabbage and cauliflower are important for me to eat.”
Ans: C
Feedback:
The patient should be instructed to eat foods that are high in folic acid such as spinach,
asparagus, and legumes. Adding spinach every day to the evening salad indicates that
teaching about folic acid nutrition has been effective. Oranges, milk, cabbage, and
cauliflower are not food items that will specifically influence the folic acid level.
18. A patient who is 6 months pregnant is complaining of a lumbar backache. What actions
should the nurse suggest to help this patient? (Select all that apply.)
A) Do pelvic rocking.
B) Walk with head high.
C) Rest and elevate the feet.
D) Wear higher heeled shoes.
E) Twist the spine at the hips.
Ans: A, B, C
Feedback:
Interventions to reduce lower lumbar backache associated with pregnancy include pelvic
rocking exercises, walking with the head high, and resting and elevating the feet. The
patient should be instructed to limit the use of high heels. Twisting the spine is not
recommended to help with a lumbar backache.
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19. A pregnant patient is observed talking with another patient holding an infant in the
clinic waiting room. What does this observation indicate to the nurse?
A) The patient is role-playing.
B) The patient is being narcissistic.
C) The patient is reworking developmental tasks.
D) The patient is ambivalent about being pregnant.
Ans: A
Feedback:
A step in preparing for parenthood is role-playing or fantasizing about what it will be
like to be a parent. This is done by a pregnant woman spending time with other pregnant
women or mothers of young children to learn how to be a mother. The pregnant patient's
behavior does not indicate narcissism. Spending time with a mother of a small child is
not reworking developmental tasks. This behavior does not demonstrate ambivalence
about being pregnant.
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Chapter 11 Nursing Care Related to Assessment of a Pregnant Family
1. During a prenatal examination, the nurse learns that a pregnant patient has a
supernumerary nipple. What should the nurse teach the patient about this finding?
A) Such growths fade with menopause.
B) Bleeding from such growths is not uncommon.
C) Such growths deepen in color during pregnancy.
D) The tendency for supernumerary nipples is genetic.
Ans: C
Feedback:
Breast changes may be one of the first things women notice in pregnancy. Any
supernumerary nipples may become darker and enlarge in size. There is no information
to support that supernumerary nipples fade with menopause or bleed. There is also no
information to support that supernumerary nipples are genetic in origin.
2. While conducting the first prenatal health history visit, the nurse learns that a pregnant
patient is taking various herbal remedies and over-the-counter medications for minor
ailments. Which nursing diagnosis should the nurse identify as being appropriate for the
patient at this time?
A) Risk for injury to fetus related to lifestyle choices
B) Deficient knowledge regarding exposure to teratogens during pregnancy
C) Health-seeking behaviors related to strong cultural desire to have a healthy child
D) Health-seeking behaviors related to guidelines for nutrition and activity during
pregnancy
Ans: B
Feedback:
The patient is taking herbal remedies and over-the-counter medications, many of which
can be teratogenic to the developing fetus. This is the most appropriate nursing
diagnosis for the nurse to select for this assessment finding. There is no enough
information to determine if the fetus is at risk because of the patient's lifestyle choices.
The patient has not asked for specific information so health-seeking behavior diagnoses
would not be appropriate for the patient at this time.
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3. When explaining what will occur during the first prenatal visit physical examination, a
pregnant patient asks why a Papanicolaou smear is being done at this time. What should
the nurse respond to the patient?
A) It helps to date the pregnancy.
B) It detects if uterine cancer is present.
C) It predicts whether cervical cancer will occur.
D) It detects cancer cells of the cervix, vulva, or vagina.
Ans: D
Feedback:
A Pap smear is taken from the endocervix at a first prenatal visit to be certain a
precancerous or cancerous condition of the uterine cervix, vulva, or vagina is not
present. A Pap smear is not used to date a pregnancy, detect uterine cancer, or predict if
cervical cancer will occur.
4. The nurse in a community clinic is identifying ways to achieve the 2020 National Health
Goals to support prenatal care. Which nursing actions would support the achievement of
these goals? (Select all that apply.)
A) Urge female patients to ingest an adequate intake of folic acid.
B) Recommend pregnant patients attend developmental childbirth classes.
C) Discuss strategies to avoid intimate partner violence with every pregnant patient.
D) Provide a play area in the waiting room for the children of patients waiting to be
seen.
E) Support pregnant patients to achieve the recommended weight gain during
pregnancy.
Ans: A, B, D, E
Feedback:
A number of 2020 National Health Goals speak directly to the importance of prenatal
care to include increasing the proportion of pregnant women who attend a series of
prepared childbirth classes, increasing the proportion of women of childbearing
potential who have an intake of at least 400 mcg of folic acid from fortified foods or
dietary supplements before pregnancy, increasing the proportion of mothers who
achieve a recommended weight gain during their pregnancies, and making sites for
prenatal care “family friendly” or maximally receptive to women and families.
Strategies to avoid intimate partner violence will not help the nurse achieve the 2020
National Health Goals for prenatal care.
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5. Which question should the nurse include when conducting a review of systems with a
patient during the first prenatal visit?
A) “Do you have a peptic ulcer?”
B) “Have you ever had a heart attack?”
C) “Have you had any neurologic diseases?”
D) “Have you had any urinary tract infections?”
Ans: D
Feedback:
Urinary tract infections are associated with preterm birth. If the patient has a history of
this type of infection, then interventions can be directed to help the patient avoid a
urinary tract infection while pregnant. Although a part of the review of systems, asking
about peptic ulcers, heart attacks, and neurologic diseases may not have as significant an
impact on the developing fetus as having urinary tract infections.
6. The nurse manager of a prenatal clinic has implemented interventions to individualize
the prenatal care experience. Which patient statement indicates that the nurse's efforts
have been successful?
A) “It was so nice to not have to wait long in the waiting room.”
B) “I really hate having my weight and blood pressure measured around other
people.”
C) “Why does everyone push breastfeeding and natural childbirth? What about what
I want?”
D) “I thought you would have more reading material on labor and delivery in the
waiting room.”
Ans: A
Feedback:
Strategies to individualize prenatal care include trying to schedule appointments so there
won't be a long wait time, providing privacy for weight and blood pressure assessments,
educating on care options and encouraging participating in decisions about care, and
providing materials on pregnancy in the waiting room.
7. The nurse is collecting a urine specimen from a pregnant patient during a prenatal visit.
For what will the nurse test this patient's urine? (Select all that apply.)
A) Protein
B) Glucose
C) Bacteria
D) Drug levels
E) White blood cells
Ans: A, B, C, E
Feedback:
Urine is tested for proteinuria, glycosuria, nitrites, and pyuria. All of these can be done
by means of test strips. The nurse will not test the patient's urine for drug levels as part
of a routine prenatal visit.
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8. At the conclusion of a prenatal assessment, the nurse determines that a patient is at risk
during the pregnancy. Which data from the patient's past illness history does the nurse
use to make this decision? (Select all that apply.)
A) Seizure disorder
B) Previous cesarean birth
C) Hypertension for 10 years
D) History of abnormal Pap smear
E) Previous treatment for gonorrhea
Ans: A, C, E
Feedback:
Past illness history criteria that place a patient at risk during pregnancy include a seizure
disorder, a chronic disease such as hypertension, and sexually transmitted infections. A
previous cesarean birth and a history of abnormal Pap smears are criteria for the
obstetrical history, which can place the patient at risk during pregnancy.
9. How should the nurse record the obstetric history for a pregnant patient who previously
delivered two live infants at term and had one abortion at 12 weeks' gestation?
A) Gravida 3, para 2
B) Gravida 3, para 3
C) Gravida 4, para 2
D) Gravida 4, para 3
Ans: A
Feedback:
Gravida is defined as a woman who has been pregnant. Para is defined as the number of
pregnancies that have reached viability, regardless of whether the infants were born
alive. The patient was pregnant three times. The patient delivered two live births. The
aborted fetus is not included in the para count. The patient was not pregnant four times.
10. A pregnant patient has an anthropoid pelvis. How should the nurse explain this finding
to the patient?
A) Transverse narrow
B) Ideal for childbearing
C) Similar in shape to a male
D) Has weaker bones than normal
Ans: A
Feedback:
In an anthropoid pelvis, the transverse diameter is narrow. A gynecoid pelvis has an
inlet that is well rounded forward and backward and has a wide pubic arch. This pelvic
type is ideal for childbirth. An android pelvis is similar in shape to that of a male. The
shape of the pelvis does not determine the strength of the bones.
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11. The nurse is preparing to measure the diagonal conjugate of a pregnant patient's pelvis.
Which anatomic landmarks will the nurse use to make this measurement?
A) Medial surface of the ischial tuberosities
B) Posterior surface of sacrum and the axis of the ischial tuberosities
C) Interior surface of the sacral prominence and the posterior surface of the
symphysis pubis
D) Anterior surface of the sacral prominence and the posterior surface of the
symphysis pubis
Ans: D
Feedback:
The diagonal conjugate is the measurement between the anterior surface of the sacral
prominence and the posterior surface of the symphysis pubis. The ischial tuberosity
diameter measurement is the distance between the ischial tuberosities or the transverse
diameter of the outlet and is made at the medial and lowermost aspect of the ischial
tuberosities at the level of the anus. Measurements are not made from the posterior
surface of the sacrum and the axis of the ischial tuberosities or the interior surface of the
sacral prominence and the posterior surface of the symphysis pubis.
12. The nurse teaches a pregnant patient the manifestations associated with complications
while pregnant. Which statement indicates that additional patient teaching is needed?
A) “Pain with urination is expected during pregnancy.”
B) “I should call the doctor if I have any vaginal bleeding.”
C) “A sudden rush of fluid means that my membranes ruptured.
D) “I should not worry if I vomit once a day for the first 12 weeks.”
Ans: A
Feedback:
Pain on urination is a symptom of a urinary infection, potentially serious because these
are associated with preterm birth. This statement indicates that additional patient
teaching is needed. The patient should call the doctor with any vaginal bleeding. A
sudden rush of fluid indicates the membranes have ruptured. Once a day vomiting is not
uncommon during the first trimester of pregnancy.
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13. A patient having an examination to check the placement of an intrauterine device (IUD)
is diagnosed as being pregnant. For which action should the nurse prepare the patient at
this time?
A) Removal of the IUD
B) Surgery to abort the fetus
C) Potential for a spontaneous abortion
D) Nothing since the IUD can remain in place
Ans: A
Feedback:
A patient may become pregnant with an intrauterine device (IUD) in place. If this
occurs, it needs to be removed to prevent infection during pregnancy. The fetus does not
need to be aborted, and the patient will not spontaneously abort because the IUD is in
place. The IUD cannot remain in place because of the risk for infection.
14. How should the nurse document a pregnant patient's gestational status using the GTPAL
system after collecting the following data?
Currently 18 weeks pregnant
Patient's fourth pregnancy
Delivered one nonviable fetus at 26 weeks
Experienced one miscarriage
Delivered one viable fetus at 38 weeks' gestation
A) 3, 2, 1, 2, 1
B) 4, 2, 2, 1, 1
C) 3, 2, 1, 1, 1
D) 4, 1, 1, 1, 1
Ans: D
Feedback:
GTPAL is a more comprehensive system for classifying pregnancy status. By this
system, the gravida classification remains the same, but para is broken down into T: the
number of full-term infants born (infants born at 37 weeks or after), P: the number of
preterm infants born (infants born before 37 weeks), A: the number of spontaneous
miscarriages or therapeutic abortions, and L: the number of living children. The patient
has been pregnant four times. The patient delivered one viable infant at 38 weeks. The
patient delivered one nonviable fetus at 26 weeks. The patient had one miscarriage. The
patient has one living child.
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15. The nurse is visiting the family of a newly pregnant patient whose spouse was
ambivalent about the pregnancy during the first prenatal visit. Which observation
indicates that the spouse is accepting the pregnancy?
A) Spouse leaves the house when the nurse arrives.
B) Spouse sits with the pregnant patient during the nurse's visit.
C) Spouse shouts down the stairs about the location of clean laundry.
D) Spouse tells the patient what needs to be obtained from the grocery store.
Ans: B
Feedback:
If childbearing is to be a family affair, it is important to determine a partner's degree of
acceptance of the pregnancy and how well prepared the spouse is of assuming a new
parenting role. After confirmation of pregnancy, include the partner in health care
information or suggestions. The spouse sitting with the pregnant patient during the
nurse's visit indicates that the spouse is accepting the pregnancy. Leaving the house,
shouting down the stairs about laundry, and giving a list of grocery items could indicate
indifference or no interest in the pending pregnancy. These actions do not support
acceptance of the pregnancy.
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Chapter 12 Nursing Care to Promote Fetal and Maternal Health
1. The nurse is planning a seminar that focuses on the 2020 National Health Goals during
pregnancy for patients who are in the first trimester of pregnancy. Which information
should the nurse include in this seminar? (Select all that apply.)
A) Refusing alcohol
B) Importance to stop smoking
C) Maintaining health appointments
D) Seeking alternative care approaches
E) Abstaining from drugs and substances
Ans: A, B, C, E
Feedback:
The 2020 National Health Goals for pregnancy include objectives to abstain from social
and binge alcohol intake, avoid smoking, receive prenatal care, and abstain from illicit
drugs. Seeking alternative care approaches is not a 2020 National Health Goal for
pregnancy.
2. A pregnant patient is experiencing a vaginal discharge and wants to douche. What
should the nurse instruct the patient about this health practice?
A) Avoid routine douching.
B) Use an alkaline solution.
C) Use only a commercial solution.
D) Use a solution that has been chilled.
Ans: A
Feedback:
Douching while pregnant is contraindicated because the force of the irrigating fluid
could cause the solution to enter the cervix and lead to uterine infection. In addition,
douching alters the pH of the vagina, leading to an increased risk of vaginal bacterial
growth. The alkalinity, purchase type, or temperature of the solution does not matter.
The pregnant patient should not douche.
3. The nurse is emphasizing the importance of adequate rest and sleep with a pregnant
patient. Which position should the nurse suggest the patient use?
A) On the back with a pillow under the head
B) On the stomach with a pillow under her breasts
C) On the back with a pillow under the knees and hips
D) On the side with the weight of the uterus on the bed
Ans: D
Feedback:
A good resting or sleeping position for a pregnant patient is a left-sided Sims' position,
with the top leg forward. This position puts the weight of the fetus on the bed, not on the
woman, and allows good circulation in lower extremities. Lying on the back could cause
the weight of the uterus to occlude the inferior vena cava impeding blood flow to the
patient and fetus. Stomach lying is not a reasonable option with the size of the uterus.
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4. A pregnant patient is experiencing leg cramps. What should the nurse include in the
patient's teaching plan as a relief measure? (Select all that apply.)
A) Avoid full leg extension.
B) Elevate lower extremities.
C) Elevate the legs on two pillows.
D) Stand on each leg and perform a squat.
E) Bend the knee and perform dorsiflexion.
Ans: A, B
Feedback:
If a pregnant woman is experiencing frequent leg cramps, she may be advised to elevate
lower extremities frequently during the day to improve circulation and avoiding full leg
extension. Elevating the legs on two pillows may or may not help the patient. The
patient should not be instructed to perform squats or dorsiflexion to help with the leg
cramps.
5. A pregnant patient is concerned that orgasm will be harmful to the developing fetus.
What should the nurse include when responding to this patient's concern?
A) Orgasm during pregnancy is potentially harmful.
B) Venous congestion in the pelvis makes orgasm painful.
C) Most women do not experience orgasm during pregnancy.
D) Some women experience orgasm intensely during pregnancy.
Ans: D
Feedback:
Because of increased pelvic congestion from the additional uterine blood supply at
midpregnancy, most women notice increased clitoral sensation and may experience
orgasm for the first time during pregnancy because of this. Orgasm during pregnancy is
not harmful. Pelvic congestion does not make orgasm painful.
6. A pregnant patient who works as a secretary at a large corporation wants to take a leave
of absence from work but is afraid of losing seniority. What should the nurse advise the
patient?
A) The patient should not ask for special favors.
B) The leave of absence should occur after the baby is born.
C) The employer cannot penalize the patient for being pregnant.
D) It is not wise for any woman to work past the seventh month of pregnancy.
Ans: C
Feedback:
Women who are unable to continue working while pregnant are protected from loss of
employment benefits during pregnancy by federal law. According to federal law, an
employer cannot deprive women of seniority rights because they take a maternity leave.
The patient is not asking for special favors. The maternity leave can occur before the
delivery because the Family Medical and Leave Act can be used once the baby is
delivered. There is no time limit about how long a pregnant patient can work.
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7. A pregnant patient is concerned that she is allergic to something because her hands have
been red and itchy since becoming pregnant. What should the nurse explain as the cause
of the patient's symptoms?
A) Allergy to fetal protein
B) Reduced serum protein
C) Increased estrogen level
D) Chorionic gonadotropin hormone secretion
Ans: C
Feedback:
Palmar erythema, or palmar pruritus, occurs in early pregnancy and is probably caused
by increased estrogen levels. Constant redness or itching of the palms can make a
woman believe she has developed an allergy. This type of itching in early pregnancy is
normal and is not caused by an allergy to fetal protein, reduced serum protein, or
chorionic gonadotropin hormone secretion.
8. The nurse is reviewing the signs of labor with a patient entering the last phase of the
third trimester of pregnancy. What should the nurse include as an indication that the
labor is beginning?
A) Excessive fatigue and headache
B) Sharp, right-sided abdominal pain
C) Sudden gush of clear fluid from the vagina
D) An increased pulse rate and upper abdominal pain
Ans: C
Feedback:
Labor may begin with rupture of the membranes, experienced either as a sudden gush or
as scanty, slow seeping of clear fluid from the vagina. Excessive fatigue, headache,
abdominal pain, or increased pulse rate are not indications that labor is beginning.
9. A pregnant patient enjoys exercising at a local health spa once a week. Which patient
comment indicates to the nurse that additional health teaching is needed?
A) “I'm learning to play table tennis.”
B) “I limit exercising to low-impact aerobics.”
C) “The gym gets hot and stuffy by midmorning.”
D) “Nothing feels nicer than a hot tub soak after exercise.”
Ans: D
Feedback:
Pregnant women should not soak for long periods in extremely hot water or hot tubs
because heat exposure for a lengthy time could lead to hyperthermia in the fetus and
birth defects, specifically esophageal atresia, omphalocele, and gastroschisis. Playing
table tennis, performing low-impact aerobics, and the environment of the gym are not
comments that indicate the need for additional teaching.
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10. An adolescent asks which sport would be safe for her to learn during pregnancy. Which
activity should the nurse suggest to the patient?
A) Skiing
B) Jogging
C) Bicycling
D) Swimming
Ans: D
Feedback:
Swimming is a good activity for pregnant women and is not contraindicated as long as
membranes are intact. It increases muscle tone but may help relieve backache.
Pregnancy is not the time to learn to ski or ride a bicycle because the lack of skill could
result in many falls. Jogging is questionable because of the strain the extra weight of
pregnancy places on the knees.
11. What advice should the nurse provide to a patient who is 4 months pregnant and owns a
cat?
A) Give it away until after delivery.
B) Refrain from cleaning the cat's dish.
C) Be careful that it doesn't scratch the skin.
D) Ask someone else to change the cat litter.
Ans: D
Feedback:
Toxoplasmosis, a protozoan infection, may be contracted through handling cat stool in
soil or cat litter. Removing a cat from the home during pregnancy as a means of
prevention is not necessary as long as the cat is healthy. The pregnant woman should be
instructed not to change a cat litter box or garden in soil in an area where cats may
defecate to avoid exposure to the disease. Cleaning the cat's dish is acceptable.
Scratches do not cause the disease.
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12. A woman who is 4 months pregnant asks what can be done to alleviate frequent heart
palpitations and leg cramps. Which nursing diagnosis would be applicable to the patient
at this time?
A) Pain related to severe complications of pregnancy
B) Health-seeking behaviors related to ways to relieve discomforts of pregnancy
C) Risk for ineffective breathing pattern related to pressure of the growing uterus
D) Impaired urinary elimination related to inability to excrete creatine from the
muscles
Ans: B
Feedback:
The patient is asking for information to reduce the symptoms of heart palpitations and
leg cramps caused by pregnancy. This is health-seeking behavior. Heart palpitations and
leg cramps are not severe complications of pregnancy. There is no evidence to suggest
that the patient is at risk for an ineffective breathing pattern. There is also no evidence to
support that the patient is experiencing impaired urinary elimination.
13. During the previous prenatal visit, the nurse instructed a pregnant patient on ways to
reduce the impact of varicosities. Which patient statement indicates that additional
teaching is needed?
A) “I drink fluid throughout the day.”
B) “I'll try not to stand for long periods.”
C) “I point my toes up and down frequently.”
D) “I wear knee-highs rather than pantyhose.”
Ans: D
Feedback:
For varicosities, the patient should be instructed to avoid constrictive knee-high hose.
Fluid intake, avoiding prolonged positions, and dorsiflexion of the feet are ways to
reduce the impact of varicosities and would not require additional teaching.
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14. A nurse is 5 weeks pregnant and works on a care area where chemotherapy is
administered to patients. Which statement indicates that this nurse needs additional
health teaching about avoiding teratogens during pregnancy?
A) “I care for about five patients a day.”
B) “I find giving emotional support taxing.”
C) “Latex gloves irritate my hands, so I don't use them.”
D) “I never accompany patients to the X-ray department.”
Ans: C
Feedback:
The nurse is not using latex gloves and is exposed to chemotherapeutic agents, which
are known teratogens during pregnancy. This nurse needs additional instruction to
reduce exposure from the chemotherapy agents. Caring for five patients a day does not
necessarily increase the nurse's exposure to teratogens. Emotional support does not
increase the nurse's exposure to teratogens. Avoiding X-rays is a positive action to avoid
teratogens.
15. What advice should the nurse provide to a pregnant patient who admits to continuing to
drink alcohol one to two times a week?
A) Avoid all alcohol while pregnant.
B) Avoid alcohol in the first trimester.
C) The effects of alcohol on the fetus are not fully understood.
D) An occasional drink is permitted only after the first trimester.
Ans: A
Feedback:
There is evidence to confirm that women who consume large quantities of alcohol
during pregnancy can have babies with congenital craniofacial deformities. It is
impossible to define a safe level of alcohol consumption. Women should be screened for
alcohol use at a first prenatal visit and advised to abstain from alcohol completely for
the remainder of their pregnancy. Refer pregnant women with alcohol addiction to an
alcohol treatment program as early in pregnancy as possible to help them reduce their
alcohol intake.
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16. A patient enjoys exercising and wants to know if it can continue to be done while
pregnant. What should the nurse instruct the patient about exercising at this time?
(Select all that apply.)
A) Drink plenty of liquids to prevent dehydration.
B) Limit strenuous exercise to no longer than 20 minutes.
C) Eat a low-protein, simple carbohydrate snack before exercising.
D) Warm up for 5 minutes by walking or cycling on low resistance.
E) Avoid exercises that require jumping or rapid changes in direction.
Ans: A, B, D, E
Feedback:
The nurse should instruct the patient to drink liquids to prevent dehydration, limit
strenuous exercise to 20 minutes, warm up before beginning an exercise session, and
avoid exercises that can jar the body. The patient should be instructed to eat a protein
and complex carbohydrate snack before exercise to maintain the serum glucose level.
17. A pregnant patient is planning travel to a foreign country as part of a work assignment
and needs immunizations. What should the nurse instruct the patient about
immunizations while pregnant?
A) Immunizations should be restricted to live viruses only.
B) There are no restrictions on immunizations while pregnant.
C) The only immunization that should be avoided is for the flu.
D) Live virus immunizations are contraindicated while pregnant.
Ans: D
Feedback:
All live virus vaccines are contraindicated during pregnancy and should not be
administered unless the risk of the disease outweighs the risk to the pregnancy because
live virus vaccines can cross the placenta and infect the fetus. The influenza vaccine is
recommended if it is flu season when visiting crowded locations.
18. A pregnant patient reports feeling pain similar to menstrual cramps. What should the
nurse explain about this patient's symptoms?
A) Exercise helps reduce the frequency of them.
B) If rhythmical, they could indicate preterm labor.
C) Lying down for a few hours will help them stop.
D) They are false labor and do not need to be reported.
Ans: B
Feedback:
Beginning as early as the 8th to 12th week of pregnancy, the uterus periodically
contracts and then relaxes again. These sensations are Braxton Hicks contractions and
can be similar to a forceful menstrual cramp. These contractions are not usually a sign
of beginning labor but should be reported for evaluation. A rhythmic pattern of even
very light but persistent contractions could be a beginning sign of preterm labor.
Exercise or rest does not reduce the frequency of Braxton Hicks contractions.
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19. A pregnant patient has a history of genital herpes lesions and has experienced outbreaks
periodically throughout the pregnancy. What should the nurse instruct the patient
regarding this virus if lesions are present at the time of delivery?
A) A cesarean section will be advised at the time of birth.
B) There are no precautions needed at the time of birth.
C) The patient will need medication immediately after birth.
D) The baby will be given a vaccination against the virus at birth.
Ans: A
Feedback:
If genital lesions are present at the time of birth, a fetus may contract the virus from
direct exposure. A woman who has existing genital lesions at the time of birth will be
advised to have a cesarean birth to reduce the risk of infecting the baby. There are
precautions that need to be undertaken if lesions are present at the time of birth. The use
of medication will depend on the patient's and infant's exposure to the virus.
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Chapter 13 The Nursing Role in Promoting Nutritional Health During Pregnancy
1. The nurse is preparing to assess the nutritional status of a patient who is 8 weeks
pregnant. What is the most effective way for the nurse to assess the patient's food intake
thus far in the pregnancy?
A) Assess skin status for hydration and color.
B) Ask the patient to describe total intake for a week.
C) Assess a list that the patient describes as a good diet.
D) Ask the patient to describe intake for the last 24 hours.
Ans: D
Feedback:
The best method for assessing a woman's nutritional intake during pregnancy is to ask
the patient to list all the food eaten within the past 24 hours, starting with waking up
until going to sleep. This method of history taking yields much more accurate
information than asking a patient how often a specific food is eaten. Assessing skin
status may provide more information about hydration that nutritional status. Assessing a
total intake for a week would be too extreme for the patient to recall. Assessing the
patient from a list of foods does not identify what the patient has most recently eaten.
2. The nurse is instructing a pregnant patient to consume a diet high in complete proteins.
Which food item should the nurse recommend as an example of a complete protein?
A) A boiled or fried egg
B) Green, leafy vegetables
C) A slice of whole grain toast
D) Applesauce or a whole apple
Ans: A
Feedback:
The protein in meat, poultry, fish, yogurt, eggs, and milk contain all nine essential
amino acids required and are considered complete proteins. The protein in nonanimal
sources does not contain all essential amino acids and are considered incomplete
proteins. Green, leafy vegetables; whole grain toast; and apples or applesauce are
carbohydrate sources.
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3. A pregnant patient asks if an over-the-counter vitamin can be taken during pregnancy
instead of the prescribed prenatal vitamin. What should the nurse explain as the chief
ingredient in prenatal vitamins that makes them important for pregnancy nutrition?
A) Folic acid
B) Vitamin C
C) Potassium
D) Vitamin B12
Ans: A
Feedback:
Folic acid is added to maternal prenatal vitamins because of the threat of developing
anemia. The pregnant patient should take a prenatal vitamin that contains a folic acid
supplement of 0.4 to 0.6 mg, which may or may not be a part of an over-the-counter
vitamin supplement. Vitamin C, potassium, and vitamin B12 are important; however, do
not have the same risk of developing a health problem if not present in a prenatal
vitamin supplement.
4. The nurse is determining the effectiveness of nutritional teaching with a pregnant
patient. Which food item that the patient selects indicates that additional teaching on
good sources of iron is needed?
A) Milk
B) Beef
C) Grains
D) Legumes
Ans: A
Feedback:
The foods richest in iron include organ meats; eggs; green, leafy vegetables; whole
grains; enriched breads; or dried fruits. Milk is not a good source of iron and indicates
that additional teaching is needed.
5. A pregnant patient tells the nurse that drinking enough fluids has always been a problem
for her. What should the nurse counsel the patient as being an adequate daily amount of
fluid to drink while pregnant?
A) Two glasses
B) Four glasses
C) Eight glasses
D) Ten glasses
Ans: C
Feedback:
Extra amounts of water are needed during pregnancy to promote kidney function
because a woman must excrete waste products for two. Eight glasses of fluid daily is a
common recommendation. Two or four glasses of fluid would not be an adequate
amount. Ten glasses of fluid might be too much for the patient to consume each day.
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6. A pregnant patient tells the nurse that saturated fats are avoided by using vegetable oil.
What additional information about vegetable oil can the nurse use to reinforce this
patient's decision?
A) Aids in fluid balance
B) Contains linoleic acid
C) Stimulates kidney function
D) Has a high-potassium content
Ans: B
Feedback:
Linoleic acid is a fat that is essential for new cell growth but cannot be manufactured by
the body. Vegetable oils such as safflower, corn, olive, peanut, and cottonseed; fatty
fish; omega-3–infused eggs; and omega-3–infused spreads are all good sources of
linoleic acid. Vegetable oil does not aid in fluid balance, stimulate kidney function, or
have high potassium content.
7. During a previous prenatal visit, the nurse focused on the importance of adequate
nutritional intake with a pregnant patient. Which assessment findings indicate that this
teaching has been effective? (Select all that apply.)
A) Shiny hair
B) Smooth tongue
C) Conjunctiva pale
D) Chipped finger nails
E) Normal muscle reflexes
Ans: A, B, E
Feedback:
Evidence of an adequate nutritional intake while pregnant includes shiny hair, smooth
tongue, and normal muscle reflexes. Pale conjunctiva could indicate iron deficiency.
Chipped fingernails could indicate inadequate protein intake.
8. The nurse is planning care for several pregnant patients. Which patient is at the greatest
risk for nutritional deficiency while pregnant?
A) Patient who rarely eats fruit
B) Patient with a 1-year-old son
C) Patient with 10-year-old twins
D) Patient who never follows a weight-reduction diet
Ans: B
Feedback:
A pregnant woman with high parity or a short interval between pregnancies such as
having a 1-year-old son may enter pregnancy with depleted nutritional reserves that she
has little to draw on during the first part of pregnancy. The other pregnant patients may
have nutritional deficiencies that can be corrected with vitamin supplementation or
adjustments in the diet.
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9. A woman who is 6 weeks pregnant is concerned because she is nauseated every
morning. Which measure should the nurse suggest the patient use to help relieve
nausea?
A) Take two aspirin on arising.
B) Delay toothbrushing until noon.
C) Delay breakfast until midmorning.
D) Take a teaspoon of baking soda before breakfast.
Ans: C
Feedback:
The traditional solution for preventing nausea is for the pregnant patient to keep dry
crackers, such as saltines, by the bedside and eat a few before rising because increasing
carbohydrate intake seems to relieve nausea better than any other nutrition remedy. The
patient can then eat a light breakfast or delay breakfast until 10 or 11 AM, which is past
the time nausea seems to persist. Aspirin is irritating to the stomach and should not be
taken. Delaying toothbrushing does not affect nausea. A teaspoon of baking soda should
not be suggested because this could adversely affect the patient's electrolyte status.
10. A pregnant patient asks the nurse what can be done for constipation. What should the
nurse recommend to the patient?
A) Mineral oil
B) Increased fiber intake
C) Eating more meat products
D) Stopping prenatal vitamins temporarily
Ans: B
Feedback:
Eating fiber-rich foods is a natural way to prevent constipation because the bulk of the
fiber left in the intestine aids evacuation. Eating fiber-rich foods this way is a better
choice for preventing constipation than taking a fiber laxative because it allows a
pregnant patient to receive nutrients from the food as well as prevent constipation. The
pregnant patient should not use mineral oil to relieve constipation because it can prevent
absorption of fat-soluble vitamins A, D, K, and E, vitamins necessary for both good
fetal and maternal health. Eating more meat products can add to the constipation. The
patient should not be advised to stop prescribed prenatal vitamins.
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11. A woman of normal weight learns that she is pregnant and asks the nurse how much
weight she should gain until delivery. What should the nurse respond to this patient?
A) Do not gain over 20 lb.
B) Any gain over 30 lb is ideal.
C) Twenty-five to 35 lb is ideal.
D) The amount of weight gain is not important.
Ans: C
Feedback:
A weight gain of 25 to 35 lb encourages fetal growth yet does not lead to a maternal
weight gain postpregnancy. A patient who is overweight might be encouraged to limit
weight gain to 20 lb while pregnant. A weight gain over 30 lb might be recommended
for the patient that is underweight. The amount of weight gain is important to ensure
adequate growth and health of the developing fetus and mother.
12. Which nutritional information should the nurse suggest to a pregnant patient who
follows a vegetarian eating plan?
A) Include at least one serving of meat daily.
B) Be careful not to eat more than four servings of fruit daily.
C) Discontinue a vegetarian diet for the remainder of pregnancy.
D) Anticipate needing a vitamin B12 supplement during pregnancy.
Ans: D
Feedback:
Vitamin B12 is found almost exclusively in animal protein, so if animal protein is
excluded from the diet, vitamin B12 deficiency can occur unless this is supplemented.
The patient should anticipate needing a vitamin B12 supplement while pregnant. The
patient is a vegetarian and will not add meat to the diet. The intake of fruit will not
adversely affect the patient or the development fetus. The patient may or may not want
to discontinue the vegetarian diet while pregnant.
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13. The nurse is planning nutritional instructions for a pregnant patient who is a Mexican
immigrant. On which areas should the nurse focus when preparing teaching for this
patient? (Select all that apply.)
A) Add fruits rich in vitamin C.
B) Consume potatoes at every meal.
C) Increase the intake of dairy products.
D) Reduce the cooking time of vegetables.
E) Limit the amount of added animal fat in foods.
Ans: A, C, D, E
Feedback:
In the Mexican culture, most vegetables are cooked for a long time so they lose most of
their nutritional value. Diet is high in fiber and starch. Animal fat is frequently added
during food preparation. The diet may be inadequate in calcium, iron, vitamin A, and
vitamin C. The nurse should instruct the patient to add fruits rich in vitamin C, increase
dairy product intake, reduce cooking times of vegetables, and limit the amount of
animal fat in the diet.
14. A patient who is 4 months pregnant is experiencing pyrosis. Which suggestion should
the nurse make to the patient to help with this health problem?
A) Try to include complex carbohydrates in meals.
B) Eat small meals and do not lie down after meals.
C) Increase vitamin intake by adding more citrus fruit.
D) Take 30 ml of milk of magnesia after every meal.
Ans: B
Feedback:
Pyrosis, or heartburn, occurs in pregnancy because the uterine pressure against the
stomach causes regurgitation into the esophagus. Eating small meals and remaining
upright limits the possibility of regurgitation. The patient should be instructed to avoid
fatty and fried foods, coffee, carbonated beverages, tomato products, and citrus juices.
Complex carbohydrates will not help with the problem. Milk of magnesia is not
recommended to be taken for pyrosis.
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15. During a prenatal appointment, a patient who is 3 months pregnant states she ingests
starch because of a craving. What should the nurse respond to this patient?
A) Suggest a hemoglobin assessment be done.
B) Kindly encourage the patient to discontinue the habit.
C) Emphasize the protein, vitamin, and iron needs of pregnancy nutrition.
D) Plan another appointment to discuss the hazards of ingesting nonfood substances.
Ans: A
Feedback:
Pica is a symptom that often accompanies iron-deficiency anemia, and the primary care
provider might need to assess the patient's serum iron level because correcting this
underlying problem with an iron supplement may correct the pica. Stopping eating the
nonfood substance may be difficult because the habit may be deeply ingrained.
Emphasizing the importance of other nutrients while pregnant will not correct the
problem. The nurse does not need to make another appointment to discuss the hazards
of ingesting nonfood substances. The teaching can be conducted during the current
appointment.
16. The nurse is planning a prenatal educational program for a community health center.
What information should the nurse include that supports the 2020 National Health Goals
for nutrition in pregnancy? (Select all that apply.)
A) Avoid foods high in fats and calories.
B) Take prenatal vitamins as prescribed.
C) Ensure a daily intake of foods with folic acid.
D) Limit the intake of foods high in simple carbohydrates.
E) Maintain adequate nutrition before becoming pregnant.
Ans: B, C, E
Feedback:
Information that the nurse should include that supports the 2020 National Health Goals
for nutrition in pregnancy include taking prenatal vitamins as prescribed because these
will contain iron and folic acid. The nurse should also teach the participants to have a
daily intake of foods with folic acid and to maintain adequate nutrition before becoming
pregnant so that those entering pregnancy will have adequate nutritional stores. There
are no specific foods that a pregnant patient should avoid such as those high in fat and
calories. All pregnant patients do not need to limit the intake of foods high in simple
carbohydrates.
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17. The nurse has identified the diagnosis of imbalanced nutrition for a pregnant patient.
Which assessment data did the nurse use to identify this diagnosis for the patient?
A) Patient eats salads at least twice a day.
B) Patient does not like potatoes or bread.
C) Patient eats red meat several times a week.
D) Patient does not want to gain any weight while pregnant.
Ans: D
Feedback:
Not wanting to gain weight while pregnant could lead to imbalanced nutrition for both
the mother and developing fetus. Eating salads and red meat will not lead to imbalanced
nutrition. Avoiding potatoes and bread will not lead to imbalanced nutrition.
18. The nurse provides instructions to a patient with hyperemesis gravidarum. Which
outcome indicates that teaching has been effective?
A) Patient has vomiting episodes only in the morning.
B) Patient is able to tolerate soft foods after episodes of vomiting.
C) Patient is able to ingest clear liquids between episodes of vomiting.
D) Patient is able to ingest a regular diet after progressing through clear liquids and
soft foods.
Ans: D
Feedback:
The pregnant patient with hyperemesis gravidarum may be hospitalized and treated with
intravenous fluids. If there is no vomiting after the first 24 hours of oral restriction,
small amounts of clear fluid can be started, and the woman discharged home. If able to
take clear fluid without vomiting, small quantities of dry toast, crackers, or cereal can be
added every 2 or 3 hours, then the woman may be gradually advanced to a soft diet and
then to a regular diet. If vomiting returns at any point, enteral or total parenteral
nutrition may be prescribed to ensure she receives adequate nutrition. Vomiting
episodes in the morning or tolerating clear liquids or soft foods between vomiting
episodes indicates that teaching has not been effective.
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Chapter 14 Preparing a Family for Childbirth and Parenting
1. The nurse is instructing a pregnant patient on tailor sitting. What is the purpose of this
exercise in pregnancy?
A) Stretches perineal muscles
B) Decreases respiratory effort
C) Strengthens abdominal muscles
D) Improves the blood supply to the uterus
Ans: A
Feedback:
: Tailor sitting stretches perineal muscles without occluding the blood supply to the
lower legs. This exercise stretches perineal muscles to aid in the delivery process. Tailor
sitting does not help with respiratory effort, strengthening abdominal muscles, or
improving blood supply to the uterus.
2. During prenatal classes, the nurse teaches pregnant patients how to perform pelvic
rocking. What should the nurse explain to the class as being the purpose of this action?
A) Helps to relieve backache
B) Stretches perineal muscles
C) Enhances respiratory excursion
D) Improves abdominal muscle tone
Ans: A
Feedback:
Pelvic rocking helps relieve backache during pregnancy and early labor by making the
lumbar spine more flexible. This exercise does not stretch perineal muscles, enhance
respiratory excursion, or improve abdominal muscle tone.
3. The nurse identifies the diagnosis of “Anxiety related to absence of significant other” as
appropriate for a pregnant patient. For which assessment finding is this diagnosis
appropriate?
A) Spouse works the night shift.
B) Mother is recovering from a total hip replacement.
C) Oldest daughter is preparing for a school dance recital.
D) Spouse is in the military and is stationed in the Middle East.
Ans: D
Feedback:
The diagnosis “Anxiety related to absence of significant other” is appropriate for the
spouse who is in the military and is stationed somewhere out of the country. The spouse
working the night shift does not mean that the spouse is not available to help the patient.
Other children are not typically identified as support people for a pregnant patient. The
patient's mother is recovering from a surgical procedure and most likely is not identified
as being a support person for the pregnant patient.
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4. A pregnant patient tells the nurse about practicing different positions to use when labor
begins. What should the nurse counsel the patient to avoid during these practice
sessions?
A) Pushing
B) Bending over
C) Pointing the toes
D) Breathing normally
Ans: A
Feedback:
Pregnant patients should not practice pushing during pregnancy because the possibility
they could rupture membranes by doing this is too great. They can practice assuming a
good position for pushing such as squatting, sitting upright, or leaning on a partner but
should always be cautioned not to actually bear down and push. Bending over, pointing
the toes, and breathing normally do not need to be avoided when practicing different
positions to use when labor begins.
5. A pregnant patient asks the nurse to explain the Lamaze philosophy of childbirth. What
should the nurse include when responding to this patient's request? (Select all that
apply.)
A) Labor should be induced.
B) Breathing patterns block pain sensations.
C) It is based on the gating control theory of pain relief.
D) Patients should be maintained on bed rest during labor.
E) Actions that are not medically necessary should be avoided.
Ans: B, C, E
Feedback:
The Lamaze philosophy of childbirth teaches that concentrating on breathing patterns
can block incoming pain sensations. This philosophy is based on the gating control
theory of pain relief. And any actions that are not medically necessary for the patient
and fetus should be avoided. The Lamaze philosophy of childbirth believes that labor
should not be induced and that patients should walk, move around, and change positions
throughout labor.
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6. The nurse working in the maternity care area is planning actions to support the 2020
National Health Goals regarding the preparation of patients for childbirth. Which action
should the nurse select to support these goals?
A) Attend pediatric advanced life support training.
B) Request to be scheduled to work in the labor suite.
C) Enroll in classes to become a childbirth instructor.
D) Become certified in infant cardiopulmonary resuscitation.
Ans: C
Feedback:
Nurses have a direct role in helping the nation achieve the 2020 National Health Goals
regarding the preparation of patients for childbirth by participating as childbirth
instructors. Attending pediatric advanced life support training, working in the labor
suite, and certification in infant cardiopulmonary resuscitation will not support the 2020
National Health Goals for childbirth.
7. Which action should the nurse include when teaching a pregnant patient effleurage?
A) Exhaling into a paper bag to prevent dizziness
B) Holding the breath and pushing with contractions
C) Lightly tracing a pattern on the abdomen with the fingertips
D) Massaging the uterine fundus at the peak of each contraction
Ans: C
Feedback:
A technique to encourage relaxation and displace pain in the Lamaze method is
effleurage, which is French for “light abdominal massage.” This action is done by
tracing a pattern on the abdomen with the fingertips. Effleurage is not breathing into a
paper bag to prevent dizziness, holding the breath and pushing with contractions, or
massaging the uterine fundus at the peak of each contraction.
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8. A patient who is newly pregnant and her spouse have decided to use the Bradley method
of childbirth. Which outcome indicates that this couple is adhering to the principles of
this birthing method?
A) The patient performs muscle-toning exercises.
B) The patient and spouse are ingesting a high-fat, low-carbohydrate diet.
C) The patient identifies that lying in bed will be the position to use during labor.
D) The spouse encourages the patient's mother to coach the patient during breathing
exercises.
Ans: A
Feedback:
The Bradley method of childbirth is based on the premise that pregnancy and childbirth
are joyful, natural processes and that a patient's partner should play an active role during
pregnancy, labor, and the early newborn period. The patient's mother is not identified as
being the partner in this method. During pregnancy, the patient performs muscle-toning
exercises and limits or omits foods that contain preservatives, animal fat, or a high salt
content. A high-fat, low-carbohydrate diet is not a part of this method. This method
encourages walking and moving around while in labor and not lying in bed.
9. A pregnant patient enrolls in an expectant parents class during the second trimester of
pregnancy. Which material should the nurse prepare to reinforce after these classes
conclude? (Select all that apply.)
A) Home safety
B) The birth process
C) Newborn nutrition
D) Types of birth settings
E) Infant immunization schedules
Ans: B, C, D
Feedback:
Expectant parents classes provide content about the birth process, newborn nutrition,
and types of birth settings. Home safety and infant immunization schedules are not a
routine part of expectant parents classes.
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10. A pregnant patient is planning to give birth to the baby at home. Which patient
statement indicates to the nurse that this patient is a good candidate for this birthing
option?
A) “All women in my family have had easy labors.”
B) “I want to have a baby without boring prenatal care.”
C) “I know nothing about birth so a hospital intimidates me.”
D) “I have no health problems and follow good self-care practices.”
Ans: D
Feedback:
To be a candidate for a home birth, a woman should be in good overall health. A family
history of easy labor is not a criterion for a home birth. Avoiding prenatal care might
jeopardize the patient's health status, leading to her not being a candidate for a home
birth. Being intimidated by hospitals is not a criterion for a home birth.
11. A pregnant patient wants to use an alternative birthing center for the birth of her baby.
Which information should the nurse provide the patient regarding this birthing
approach?
A) Birth is viewed as a wellness event.
B) There are no physicians in attendance.
C) Breastfeeding is not encouraged or supported.
D) A birthing center has no advantages over a home birth.
Ans: A
Feedback:
Alternative birthing centers are wellness-oriented childbirth facilities. These facilities
are located near an acute care hospital in the event a physician is needed for the birthing
process. Alternative birthing centers do not promote nor condone any specific action
such as breastfeeding. Because a birthing center is located near a hospital, they are safer
than home deliveries.
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12. A pregnant patient has chosen to give birth in a hospital that is designated as mother
friendly. What information should the nurse teach the patient to expect when admitted
for the birth of her baby? (Select all that apply.)
A) Application of continuous fetal monitoring prior to delivery
B) Routine policies for perineal shaving and admission enemas
C) Accurate information about procedures, drugs, and tests
D) Algorithm to determine when to artificially rupture the membranes
E) Support for making informed choices about what is best for the baby
Ans: C, E
Feedback:
Mother-friendly hospitals approach birth as a healthy and joyous experience. The patient
should expect to receive accurate information about procedures, drugs, and tests and
receive support for making informed choices about what is best for the baby. To qualify
as a mother-friendly hospital, there should not be routine policies for fetal monitoring,
perineal shaving, admission enemas, or artificial rupturing of the membranes.
13. The nurse assessing a patient in active labor notes that the patient's respiratory rate is 36
breaths/min and shallow. From this information, what should the nurse determine as
being the status of the patient's cervical dilation?
A) 0 to 1 cm
B) 2 to 3 cm
C) 4 to 6 cm
D) 7 to 10 cm
Ans: C
Feedback:
Respirations up to 40 breaths/min and shallow is a level of breathing when cervical
dilation is between 4 and 6 cm. Slow deep chest breathing of comfortable but full
respirations at a rate of 6 to 12 breaths/min is used for early contractions in labor when
the cervical dilation is between 0 and 3 cm. More rapid breathing at a rate of 50 to 70
breaths/min is used when cervical dilation is between 7 and 10 cm.
14. The nurse reminds a patient in active labor to perform cleansing breaths. Why should
the nurse encourage the patient to do this type of breathing?
A) Ensures fetal perfusion
B) Prevents hyperventilation
C) Promotes hypoventilation
D) Encourages cervical dilation
Ans: B
Feedback:
Cleansing breaths are important because they limit the possibility of either
hyperventilation or hypoventilation, both of which can happen with rapid breathing
patterns. Cleansing breaths do not ensure fetal perfusion or promote cervical dilation.
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15. The nurse is assisting a pregnant patient learn gating control mechanisms to control pain
during labor. Which techniques will the nurse teach the patient? (Select all that apply.)
A) Distraction
B) Reducing anxiety
C) Receiving an epidural
D) Cutaneous stimulation
E) Use of patient-controlled analgesia
Ans: A, B, D
Feedback:
The gate control mechanisms of pain control are capable of halting an impulse at the
level of the spinal cord so the impulse is never perceived at the brain level as pain.
Techniques that can assist gating mechanisms are distraction, reduction of anxiety, and
cutaneous stimulation. An epidural and use of patient-controlled analgesia are not
techniques to assist the gating mechanism for pain control.
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Chapter 15 Nursing Care of a Family During Labor and Birth
1. The fetus of a patient in labor is in a vertex presentation and at a –1 station. How should
the nurse interpret the location of the fetal head?
A) Floating
B) Engaged
C) Crowning
D) At the ischial spines
Ans: A
Feedback:
Engagement refers to the settling of the presenting part of a fetus far enough into the
pelvis that it rests at the level of the ischial spines, the midpoint of the pelvis. The
degree of engagement is established by vaginal and cervical examination. Station refers
to the relationship of the presenting part of the fetus to the level of the ischial spines. If
the presenting part is above the spines, the distance is measured and described as minus
stations, such as –1. The fetal head is currently floating. The head would be engaged if it
were at the level of the ischial spines. Crowning is when the top of the fetal head is
visible and birth is imminent.
2. When the membranes of a pregnant patient rupture during labor, the nurse determines
that the patient and fetus are in danger. What did the nurse assess at the time of
membrane rupture?
A) Meconium-stained amniotic fluid
B) Fetus presenting in an LOA position
C) Maternal pulse of 90 to 95 beats/min
D) Blood-tinged vaginal discharge at full dilation
Ans: A
Feedback:
Meconium staining means that the fetus has lost rectal sphincter control, allowing
meconium to pass into the amniotic fluid. It may indicate a fetus has or is experiencing
hypoxia, which stimulates the vagal reflex and leads to increased bowel motility. The
fetal presentation is not assessed during membrane rupture. The maternal pulse rate of
90 to 95 beats/min is expected during labor. Blood-tinged vaginal discharge at full
dilation is an expected finding.
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3. The nurse is instructing a patient who is in the third trimester of pregnancy on the
difference between false and true labor contractions. What should the nurse emphasize
as being characteristics of false labor contraction? (Select all that apply.)
A) False labor contractions are irregular.
B) True labor contractions disappear when asleep.
C) False labor contractions lead to cervical dilation.
D) True labor contractions occur in the abdomen and groin.
E) False labor contractions do not increase in duration, frequency, and intensity.
Ans: A, E
Feedback:
False labor contractions are irregular. True labor contractions increase in duration,
frequency, and intensity. False labor contractions disappear when asleep and occur in
the abdomen and groin. True labor contractions lead to cervical dilation.
4. The nurse is preparing to assess the frequency of contractions for a patient in labor.
Which process should the nurse use to time the contractions?
A) Number of contractions that occur in 5 minutes
B) The end of one contraction to the beginning of the next
C) The interval between the acmes of two consecutive contractions
D) The interval between the beginning and the end of one contraction
Ans: D
Feedback:
To determine the beginning of a contraction without a monitor, rest a hand on a
woman's abdomen at the fundus of the uterus very gently until you sense the gradual
tensing and upward rising of the fundus that accompanies a contraction. Time the
duration of the contraction from the moment the uterus first tenses until it has relaxed
again. Contractions are not timed by measuring the number of contractions in 5 minutes,
the end of one contraction to the beginning of the next, or by using the interval between
the acmes of two consecutive contractions.
5. After pelvic measurements, a patient who is 20 weeks pregnant is informed that the
diagonal conjugate diameter is narrow. For which component of labor should the nurse
plan care to address?
A) Powers
B) Passage
C) Passenger
D) Psychological outlook
Ans: B
Feedback:
Passage focuses on the size and contour of the pregnant patient's pelvis. Passenger
addresses the size, position, and presentation of the fetus. Powers determine if uterine
factors for labor are adequate. Psychological outlook focuses on the pregnant patient's
ability to view labor as a positive experience.
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6. During labor, a fetus is identified as having uteroplacental insufficiency. Which tracing
should the nurse assess on the monitor to confirm this finding?
A) Variable decelerations that are too unpredictable to count
B) Fetal baseline rate increasing at least 5 mmHg with contractions
C) A shallow deceleration occurring with the beginning of contractions
D) Fetal heart rate declining late with contractions and remaining depressed
Ans: D
Feedback:
Late decelerations are those that are delayed until 30 to 40 seconds after the onset of a
contraction and continue beyond the end of a contraction. This is an ominous pattern in
labor because it suggests uteroplacental insufficiency or decreased blood flow through
the intervillous spaces of the uterus during uterine contractions. With uteroplacental
insufficiency, the nurse will not observe on the monitor tracing variable unpredictable
decelerations, an increase in fetal heart rate with contractions, or shallow decelerations
at the beginning of contractions.
7. The nurse providing care to patients in the labor and delivery suite desires to support the
2020 National Health Goals to reduce maternal and infant mortality after labor and
birth. Which action should the nurse perform to support these goals?
A) Support laboring patients through the use of controlled breathing techniques.
B) Encourage laboring patients to use analgesia to control painful contractions.
C) Recommend the use of epidural and spinal anesthesia to aid in the labor process.
D) Apply specific infection control practices during the labor and birthing processes.
Ans: A
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for reducing
maternal and infant mortality after labor and birth by teaching patients as much as
possible about labor, so they are able to use as little analgesia and anesthesia as possible.
The less anesthesia and analgesia used, the fewer the complications, which can result in
fetal or maternal death. One approach would be to support laboring patients through the
use of controlled breathing techniques. Infection control practices are not identified as
strategies to reduce maternal and infant mortality after labor and birth.
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8. During active labor, the nurse observes the patient crying during contractions and not
using breathing techniques learned during prenatal classes. Which nursing diagnosis
would be appropriate for the patient at this time?
A) Risk for fluid volume deficit
B) Anxiety related to stress of labor
C) Risk for ineffective breathing pattern related to breathing exercises
D) Powerlessness related to duration of labor
Ans: C
Feedback:
Hyperventilation occurs when the patient exhales more deeply than inhaling. As a result,
extra carbon dioxide is blown off, and respiratory alkalosis results. This can occur
during actual labor. The best way to manage hyperventilation is to prevent it by
coaching the patient to end all breathing sessions with a long cleansing breath to help
restore carbon dioxide balance. Difficulty using breathing techniques will not cause a
risk for fluid volume deficit, anxiety related to stress of labor, or powerlessness related
to duration of labor.
9. The nurse is teaching a pregnant patient the cardinal movements of labor. What should
the nurse explain that occurs once the fetal head presses on the sacral nerves at the
pelvic floor?
A) The fetal head bends forward onto the chest.
B) The fetal head rotates into a transverse position.
C) The head extends so that the face and chin are born.
D) The shoulders move into an anteroposterior position.
Ans: A
Feedback:
The cardinal movements of labor are descent, flexion, internal rotation, extension,
external rotation, and expulsion. In descent, the fetal head bends forward onto the chest
once the head presses on the sacral nerves at the pelvic floor. The fetal head rotates into
a transverse position prior to expulsion. The head extends so that the face and chin are
born during extension. The shoulders move into an anteroposterior position during
external rotation.
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10. The nurse is determining care for a patient entering the active phase of labor. Which
outcome would be the most appropriate for the patient at this time?
A) Patient will develop an irresistible urge to push.
B) Patient will combat feelings of nausea to prevent vomiting.
C) Patient will remain in the supine position during contractions.
D) Patient will adjust body to attain the most comfortable position.
Ans: D
Feedback:
During the active phase of labor, contractions grow so much stronger and last so much
longer than they did in the latent phase. An appropriate outcome at this time would be
that the patient keeps active and assumes whatever position is most comfortable during
this time, except flat on the back or supine. An irresistible urge to push and nausea and
vomiting may occur during the transition phase of labor.
11. During the active stage of labor, a patient's membranes spontaneously rupture. Which
action should the nurse do first after this occurs?
A) Turn the patient onto the left side.
B) Assess fetal heart rate for fetal safety.
C) Test a sample of amniotic fluid for protein.
D) Instruct to bear down with the next contraction.
Ans: B
Feedback:
If membranes rupture during labor, the fetal heart rate should be assessed immediately
to be certain that the umbilical cord hasn't prolapsed and is now being compressed
against the cervix by the fetal head. The patient does not need to be turned onto the left
side. The amniotic fluid is tested for pH and not protein. Bearing down at this time
could be dangerous, considering there is no way of knowing how much the cervix has
dilated at the time of membrane rupture.
12. The nurse is concerned that a patient in the second stage of labor will experience a drop
in blood pressure. What should the nurse do to prevent this from occurring?
A) Position the patient supine.
B) Encourage oral fluid intake.
C) Administer intravenous fluids.
D) Position the patient side-lying.
Ans: D
Feedback:
If a patient lies in a supine position and pushes during the second stage of labor,
pressure of the uterus on the vena cava causes the blood pressure to drop, leading to
hypotension. A side-lying position during the second stage of labor can help avoid such
a problem. Fluids would be indicated if the patient is having epidural anesthesia.
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13. A pregnant patient in labor is being encouraged to push with contractions. In which
position should the nurse assist to help the patient at this time?
A) Squatting while holding the breath
B) Lying on side, arms grasped on abdomen
C) Lying supine with legs in lithotomy stirrups
D) Semi-Fowler's position with legs bent against the abdomen
Ans: D
Feedback:
Pushing is usually best done from a semi-Fowler's position with legs raised against the
abdomen. Lying on the side or supine in the lithotomy position are not positions
conducive to successful delivery. The patient should be coached to not hold the breath
during a contraction or pushing because this could increase intrathoracic pressure, which
could interfere with blood supply to the uterus.
14. After assessment, the nurse determines that a pregnant patient's fetus has a face
presentation that is pointing to the patient's left side with transverse pointing. How
should the nurse document this assessment finding?
A) LCT
B) LMT
C) LOT
D) ROA
Ans: B
Feedback:
Fetal position is the relationship of the presenting part to a specific quadrant and side of
the patient's pelvis. The maternal pelvis is divided into four quadrants according to the
mother's right and left. Four parts of a fetus are landmarks to describe the relationship of
the presenting part to one of the pelvic quadrants that include the occiput (O), the chin
(mentum [M]), the sacrum (Sa), or the acromion process (A). Position is indicated by an
abbreviation of three letters. The first letter defines whether the landmark is pointing to
the patient's right (R) or left (L).The middle letter denotes the fetal landmark. The last
letter defines whether the landmark points anteriorly (A), posteriorly (P), or transversely
(T). The nurse should document LMT. The other choices are incorrect interpretation of
the findings and use of the abbreviations.
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15. While conducting Leopold maneuvers, the nurse determines that the fourth maneuver
does not need to be done. What information caused the nurse to make this decision?
A) The fetus is in a cephalic presentation.
B) The fetus is not in a cephalic presentation.
C) The nurse palpated angular bumps and nodules.
D) The nurse palpated a round and hard mass that moves freely.
Ans: B
Feedback:
The fourth Leopold maneuver is only done if the fetus is in a cephalic presentation
because it determines fetal attitude and degree of fetal extension into the pelvis. Angular
bumps and nodules indicate the fetal knees, elbows, hands, and fingers. A round hard
mass that moves freely is the fetal head.
16. After delivery of the placenta, a patient's uterus is sluggish to contract. What should the
nurse prepare to do to assist the patient at this time?
A) Administer intravenous fluids.
B) Measure blood pressure every 15 minutes.
C) Administer oxytocin (Pitocin) as prescribed.
D) Prepare to administer blood products as prescribed.
Ans: C
Feedback:
After placenta inspection, if the patient's uterus has not contracted firmly on its own, the
primary care provider may prescribe oxytocin (Pitocin) to help uterine contraction.
Intravenous fluids and blood pressure measurement will not encourage uterine contract.
It is premature to anticipate the patient needing a blood transfusion at this time.
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Chapter 16 The Nursing Role in Providing Comfort During Labor and Birth
1. When entering the second phase of labor, a patient tells the nurse that the pain is severe
and is unsure if pain medication should be used. Which nursing diagnosis should the
nurse use to guide the care of the patient at this time?
A) Pain related to labor contractions
B) Powerlessness related to the duration and intensity of labor
C) Decision conflict related to the use of analgesia during labor
D) Anxiety related to lack of knowledge about normal labor processes
Ans: C
Feedback:
The patient is in conflict regarding whether or not to use pain medication during labor at
this time. This is an example of decisional conflict. The patient's need is much more
than experiencing pain during labor contractions. There is no enough information to
support that the patient is experiencing powerlessness. The patient is not demonstrating
anxiety related to the labor process.
2. A patient in labor is prescribed transcutaneous electrical nerve stimulation (TENS) to
help with pain relief during labor. How should the nurse explain the process of pain
relief with this method?
A) Counterirritation stimulation blocks pain from traveling to the spinal cord.
B) Needles are inserted along meridians to release endorphins and control pain.
C) A machine is used to measure the patient's ability to relax during contractions.
D) Small injections of sterile saline reduce are used to reduce the amount of back
pain.
Ans: A
Feedback:
Transcutaneous electrical nerve stimulation (TENS) works to relieve pain by applying
counterirritation to nociceptors. Low-intensity electrical stimulation blocks the afferent
fibers, preventing pain from traveling to the spinal cord synapses from the uterus.
Needles being inserted along meridians to release endorphins explain acupuncture. A
machine to measure the patient's ability to relax during contractions explains
biofeedback. Small injections of saline to reduce back pain explain intracutaneous nerve
stimulation.
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3. The health care provider is reluctant to provide pain medication to a patient delivering a
preterm fetus. What should the nurse explain to the patient as the reason for the preterm
fetus being more affected by medication?
A) Affinity of the preterm fetus to fat-soluble drugs
B) Inability of the immature liver to metabolize or inactivate drugs
C) Affinity of the preterm fetus to drugs that are strongly bound to protein
D) Inability of the preterm fetus to use drugs with a molecular weight over 1,000
Ans: B
Feedback:
A preterm fetus, which has an immature liver and is unable to metabolize or inactivate
drugs, is generally more affected by drugs than a term fetus. A preterm fetus does not
have an affinity to drugs that are fat soluble or strongly bound to protein. The preterm
fetus is not able to metabolize drugs because of an immature liver, which has nothing to
do with the molecular weight of the medication.
4. When teaching the pregnant patient about self-medicating for pain during labor, why did
the nurse instruct the patient to avoid taking acetylsalicylic acid?
A) Development of respiratory depression in the newborn
B) Interference with the ability to concentrate on contractions
C) Interference with blood coagulation with increased risk of bleeding in mother or
infant
D) Competition with bilirubin-binding sites in fetal circulation increases risk of
kernicterus.
Ans: C
Feedback:
The nurse should caution the pregnant patient not to take acetylsalicylic acid (aspirin)
for pain in labor because aspirin interferes with blood coagulation, increasing the risk
for bleeding in the newborn or patient. Aspirin does not cause respiratory depression in
the newborn, interfere with contractions, or compete with bilirubin-binding cites in fetal
circulation.
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5. The nurse is preparing materials to instruct a pregnant patient about the use of a local
anesthetic to block specific nerve pathways. About which type of pain reduction
technique will the nurse instruct the patient?
A) General anesthesia
B) Pressure anesthesia
C) Regional anesthesia
D) Pudendal nerve block
Ans: C
Feedback:
Regional anesthesia is the injection of a local anesthetic to block specific nerve
pathways. This achieves pain relief by blocking sodium and potassium transport in the
nerve membrane so the nerve is unable to conduct sensations. General anesthesia is
rarely used and is not referred to as being general anesthesia. Pressure anesthesia results
from the fetal head pressing against the stretched perineum. A pudendal nerve block is
the injection of a local anesthetic through the vagina to anesthetize the pudendal nerve.
6. The nurse caring for pregnant patients is identifying interventions to support the 2020
National Health Goals regarding pain relief during labor. Which interventions support
these goals? (Select all that apply.)
A) Encourage pregnant patients to prepare for childbirth by attending classes.
B) Discuss the advantages of using epidural or spinal anesthesia during labor.
C) Review the various opioid analgesics that can be used to control the pain of labor.
D) Review the different breathing techniques that help with pain control during labor.
E) Explain the various complementary and alternative therapies to help with pain
control.
Ans: A, D, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals regarding pain relief
during labor by educating women about the advantages of preparing for childbirth and
helping them to use breathing patterns or other complementary and alternative therapies
and techniques during labor so they need a minimum of analgesia and anesthesia. These
goals would not be achieved by discussing the use of epidural or spinal anesthesia or by
reviewing the various opioid analgesics available for use during labor.
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7. The spouse of a pregnant patient is concerned about the risk of paralysis from an
epidural block being used during labor. What should the nurse respond to the spouse's
concern?
A) “I have never read or heard of this happening.”
B) “The injection is given in the space outside the spinal cord.”
C) “An injury is unlikely because of expert professional care given.”
D) “The injection is given at the third or fourth thoracic vertebrae so paralysis is not a
problem.”
Ans: B
Feedback:
An anesthetic agent placed inside the ligamentum flavum in the epidural space is
epidural anesthesia. An epidural is placed in the space at the L4–L5, L3–L4, or L2–L3
areas to block the spinal nerve roots in the space and the sympathetic nerve fibers that
travel with them. The nurse should not minimize the spouse's concern because the nurse
has never read or heard of this occurring. An injury can occur with any invasive
procedure.
8. A pregnant patient nearing her due date expresses anxiety over the labor and delivery
process. Which outcome should the nurse select as appropriate for the patient during the
delivery process?
A) Patient requests pain medication throughout the labor process.
B) Patient uses breathing techniques to control anxiety and pain during labor.
C) Patient tolerates the use of sanitary napkins to absorb vaginal secretions during
labor.
D) Patient refuses complementary and alternative techniques to control pain during
labor.
Ans: B
Feedback:
An outcome that indicates that the patient has less anxiety during labor and delivery
would be the use of breathing techniques to control anxiety and pain during labor.
Requesting pain medication, using sanitary napkins, and refusing complementary and
alternative pain management techniques are not appropriate outcomes for labor and
delivery.
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9. Immediately following an epidural block, a pregnant patient's blood pressure suddenly
falls to 90/50 mmHg. What action should the nurse do first?
A) Place the patient supine.
B) Raise the head of the bed.
C) Ask the patient to take deep breaths.
D) Turn onto the left side or raise the legs.
Ans: D
Feedback:
To help prevent supine hypotension syndrome, place the pregnant patient on the left side
after an epidural block. If hypotension should occur, the patient's legs should be raised
in addition to providing oxygen, intravenous fluids, and medication. The supine position
encourages hypotension syndrome. Raising the head of the bed and deep breathing are
not interventions to help with hypotension syndrome.
10. During labor, a pregnant patient's doula uses therapeutic touch and massage. Which
outcome indicates that these approaches have been effective?
A) The patient is not complaining of leg cramps.
B) The patient is not requesting pain medication.
C) The patient is focusing on a painting during contractions.
D) The patient asks for a cold compress at the end of a contraction.
Ans: B
Feedback:
Touch and massage work to relieve pain by increasing the release of endorphins. Both
techniques may also work because they serve as forms of distraction. Many women find
massage helpful in the first and second stages of labor. The use of therapeutic touch and
massage for the patient in labor is not used to reduce leg cramp. Focusing on a painting
during contractions is a form of distraction. Asking for a cold compress at the end of a
contraction is not directly related to the use of therapeutic touch and massage during
labor.
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11. A patient in labor who is dilated 7 cm reports that narcotic pain medication given 3
hours ago has worn off and is asking for another dose. How should the nurse respond to
this request?
A) “I will get permission from your doctor.”
B) “Your stage of labor makes giving another dose unsafe.”
C) “It is too early as the medication should be given only every 4 hours.”
D) “Since it has been over 3 hours, you should be able to have more of the
medication.”
Ans: B
Feedback:
The timing of administration of narcotics in labor is especially important. If given close
to birth, because the fetal liver takes 2 to 3 hours to activate a drug, the effect will not be
registered in the fetus for 2 to 3 hours after maternal administration. For this reason,
narcotics are preferably given when the mother is more than 3 hours away from birth.
This allows the peak action of the drug in the fetus to have passed by the time of birth.
The nurse does not need to get permission from the physician. Pain medication can be
provided when needed and not on a set schedule of every 4 hours. The patient is nearing
delivery so 3 hours from the last dose will not influence the decision to provide more
medication.
12. The physician of a patient in labor decides that an emergency cesarean birth is required
to safely deliver the fetus. When preparing the operating room suite for this procedure,
which medications should the nurse ensure are available for possible use? (Select all
that apply.)
A) Diazepam
B) Ephedrine
C) Acetaminophen
D) Atropine sulfate
E) Lactated Ringer's solution
Ans: A, B, D
Feedback:
To ensure safe general anesthesia administration, specific drugs must be readily
available, which include diazepam to control seizures, ephedrine to use if the blood
pressure falls, and atropine sulfate to dry secretions and prevent aspiration.
Acetaminophen and lactated Ringer's solution are not specifically identified for use
using general anesthesia.
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13. A patient in labor with chronic back pain tells the nurse about taking a dose of
hydrocodone/acetaminophen (Vicodin) for labor pain prior to coming to the hospital.
What should the nurse prepare to do once the fetus is delivered?
A) Evaluate the fetus for withdrawal symptoms.
B) Inform the physician so that liver effects can be monitored.
C) Suggest that no additional narcotic pain medication be provided during labor.
D) Coach the patient in breathing techniques because other pain medication is
contraindicated.
E) Request that the physician prescribe the same medication to be used for pain
during labor.
Ans: A, B
Feedback:
A typical prescription drug abused by women is hydrocodone/acetaminophen (Vicodin)
because this is frequently prescribed for chronic back pain. The half-life of this drug is
about 2 hours in addicted women. Even though it appears to have little effect on
newborns, the newborn needs to be observed for both withdrawal and liver effects. The
patient can receive other narcotic pain medication during labor. Other pain medication is
not contraindicated for this patient. There are other, more safe pain medications that can
be prescribed for the patient and fetus during labor.
14. A pregnant patient planning for labor is asking questions about pain control options.
What should the nurse explain about pain control during labor?
A) The physician will decide how much pain relief is needed during labor.
B) Pain medication should be started immediately when contractions are thought to
begin.
C) Any medication should have maximum effect for the patient and minimal effect
on the fetus.
D) Any medication will interfere with the ability of the uterus to contract during
labor and delivery.
Ans: C
Feedback:
Any pain medication should have maximum effect for the patient and minimal effect on
the fetus. The patient has the right to choose how much pain relief is wanted or used.
Pain relief should be provided only after labor is well established. Medication should
not interfere with the ability of the uterus to contract during labor and delivery. All
medication does not interfere with this ability.
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15. A pregnant patient received a narcotic analgesic 2 hours before delivery. The newborn is
lethargic and difficult to arouse. What should the nurse prepare to do to help this
newborn?
A) Administer intravenous fluids.
B) Apply oxygen and place in a heated bassinet.
C) Administer naloxone hydrochloride (Narcan).
D) Provide tactile stimulation to encourage crying.
Ans: C
Feedback:
Naloxone hydrochloride (Narcan) is a narcotic antagonist that counteracts the effect of
narcotic analgesics. It is used to counteract respiratory depression in newborns when a
woman has received a narcotic analgesic during labor. Intravenous fluids, oxygen, a
heated bassinet, or tactile stimulation will not counteract the effects of a narcotic
analgesic given before delivery.
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Chapter 17 Nursing Care of a Postpartal Family
1. The nurse notices that a new mother who is beginning postpartum day 2 handles the
newborn tentatively and does not kiss the child when holding him. What should the
nurse suspect as the probable reason for this behavior?
A) Disappointment with the child's sex
B) Difficulty accepting the role changes
C) Reacting normally to accepting a new child
D) Cultural customs do not include kissing children
Ans: C
Feedback:
More often, a woman enters into a relationship with her newborn tentatively and with
qualms and conflicts that must be addressed before the relationship can be meaningful.
This is because parental love is only partly instinctive. The tentative behavior does not
indicate disappointment with the child's sex, difficulty accepting role changes, or
cultural customs that do not include kissing children.
2. While documenting patient care, the nurse notes that a postpartum patient is accepting
the birth of the child well. What did the nurse most likely observe to come to this
conclusion?
A) Names the child after a well-loved friend
B) Asks the nurse to take a photo of the child
C) Turns the face to meet the infant's eyes when holding the baby
D) Comments that the baby has the most hair of any in the nursery
Ans: C
Feedback:
Looking directly at the newborn's face, with direct eye contact or the en face position, is
a sign a woman is beginning effective attachment. Naming the child after a well-loved
friend, taking a photo of the child, or commenting on the child's hair are not indications
that the postpartum patient is accepting the birth of the child well.
3. The nurse assesses a postpartum patient's discharge as being moderate in amount and
red in color. How should the nurse document the appearance of the lochia?
A) Lochia alba
B) Lochia rubra
C) Lochia serosa
D) Lochia normalia
Ans: B
Feedback:
Lochia that is red in color, or bloody, is termed lochia rubra. Lochia alba is colorless
flow that occurs around postpartum day 10. Lochia serosa is pink or brown in color and
appears around postpartum day 4. Lochia normalia is not a term used to describe lochia.
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4. While observing care being provided to an infant, the new mother looks at the nurse
repeatedly and asks, “Am I doing this the right way?” Which nursing diagnosis should
the nurse select to guide the care needs of the mother at this time?
A) Health-seeking behaviors related to care of newborn
B) Ineffective coping related to expectation to provide newborn care
C) Risk for altered family coping related to an additional family member
D) Risk for impaired parenting related to disappointment in the sex of the child
Ans: A
Feedback:
The new mother is asking the nurse to validate actions being performed while providing
newborn care. The nursing diagnosis most appropriate for the new mother at this time
would be health-seeking behaviors related to care of the newborn. The new mother is
not demonstrating signs of ineffective coping. There is no information to support a risk
for altered family coping or risk for impaired parenting.
5. A postpartum patient is reluctant to begin taking warm sitz baths. What should the nurse
emphasize when teaching the patient about this treatment approach?
A) Sitz baths may lead to increased postpartal infection.
B) Sitz baths increase the blood supply to the perineal area.
C) Sitz baths cause perineal vasoconstriction and decreased bleeding.
D) The longer a sitz bath is continued, the more therapeutic it becomes.
Ans: B
Feedback:
Moist heat with a sitz bath is an effective way to increase circulation to the perineum,
provide comfort, reduce edema, and promote healing. Sitz baths do not cause postpartal
infections. Sitz baths do not cause perineal vasoconstriction and decreased bleeding.
Every use of a sitz bath is therapeutic.
6. The nurse is evaluating the effectiveness of teaching on perineal care provided to a
postpartum patient. Which outcome indicates that teaching has been effective?
A) Patient performs perineal care independently with every morning shower.
B) Patient explains the purpose of performing perineal care at least once a day.
C) Patient flushes the commode before standing when performing perineal care.
D) Patient washes the perineum from back to front when performing perineal care.
Ans: A
Feedback:
The nurse should instruct the postpartum patient to include perineal care as part of a
daily bath or shower and after every voiding or bowel movement. The patient should
stand before flushing the commode when performing perineal care because water from
the commode can splash the perineum and cause an infection. The patient should be
instructed to wash the perineum from front to back to reduce the potential for
contamination from the rectal area.
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7. The nurse is concerned that a new mother is developing a postpartum complication.
What did the nurse most likely assess in this patient?
A) Absence of lochia
B) Red-colored lochia for the first 24 hours
C) Lochia that is the color of menstrual blood
D) Lochia appearing pinkish-brown on the fourth day
Ans: A
Feedback:
Lochia should never be absent during the first 1 to 3 weeks because absence of lochia
may indicate postpartal infection. Red-colored lochia for the first 24 hours is normal.
Lochia that is the color of menstrual blood is normal. Lochia appearing pinkish-brown
on the fourth postpartum day is normal.
8. The nurse is assessing the fundus of a patient on postpartum day 2. What should the
nurse expect when palpating the fundus?
A) Fundus 4 cm above symphysis pubis and firm
B) Fundus height 4 cm below umbilicus and midline
C) Fundus two fingerbreadths below umbilicus and firm
D) Fundus two fingerbreadths above symphysis pubis and hard
Ans: C
Feedback:
Because uterine contraction begins immediately after placental delivery, the fundus of
the uterus is palpable through the abdominal wall, halfway between the umbilicus and
the symphysis pubis, within a few minutes after birth. One hour later, it will rise to the
level of the umbilicus, where it remains for approximately the next 24 hours. From then
on, it decreases one fingerbreadth or centimeter per day and will be palpable 1 cm below
the umbilicus. For the second postpartal day, the uterus will be two fingerbreadths or
centimeters below the umbilicus. The fundus should not be palpated 4 cm above the
symphysis pubis, 4 cm below the umbilicus, or two fingerbreadths above the symphysis
pubis on the second postpartum day. The fundus should not be hard.
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9. The nurse manager of a postpartum care area is planning educational sessions for the
nursing staff to support the 2020 National Health Goals for postpartum care. Which
information should be included in this staff training? (Select all that apply.)
A) Encourage postpartum patients to participate in breastfeeding.
B) Provide information on reproductive life planning if requested.
C) Suggest postpartum patients remain on bed rest for at least 2 postpartum days.
D) Recommend new mothers to attend prenatal classes to learn infant care after
delivery.
E) Explain the importance of close observation to detect postpartum maternal
hemorrhage.
Ans: A, B, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for postpartum care
by maintaining close observation in the immediate postpartal period to detect maternal
hemorrhage, encouraging and supporting women as they begin breastfeeding, and
ensuring women receive reproductive life planning information if desired. Bed rest and
attending prenatal classes to learn newborn care are not strategies to support the 2020
National Health Goals for postpartum care.
10. A postpartum patient is concerned about loose tissue around the abdominal area. Which
exercise should the nurse recommend that the patient begin on postpartum day 2 to
strengthen and tighten these muscles?
A) Sit-ups
B) Chin-to-chest
C) Pelvic rocking
D) Kegel exercises
Ans: B
Feedback:
The chin-to-chest exercise is excellent for the second day to tighten abdominal muscles.
The exercise can be done 3 or 4 times a day, and the patient should feel the abdominal
muscles pull and tighten if it is being done correctly. Sit-ups, pelvic rocking, and Kegel
exercises are not identified to assist with tightening the muscles of the abdominal
region.
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11. A postpartum patient is experiencing painful hemorrhoids. Which position should the
nurse suggest the patient use when resting?
A) Supine
B) Sims position
C) Knee–chest position
D) Trendelenburg position
Ans: B
Feedback:
Assuming a Sims position several times a day aids in good venous return to the rectal
area and reduces the discomfort of hemorrhoids. Supine, knee–chest, and Trendelenburg
are not recommended positions to aid in the pain of hemorrhoids.
12. The nurse provides discharge instructions to a postpartum patient. Which patient
statement indicates that teaching has been effective?
A) “I should limit stair climbing to four times a day.”
B) “I can have coitus at any time after returning home.”
C) “I should plan to return to my full-time job after 6 weeks.”
D) “I should notify the physician if my discharge decreases in amount.”
Ans: C
Feedback:
It is usually advised that a woman not return to an outside job for at least 3 to 6 weeks
not only for her own health but also for enjoyment of the early weeks with the newborn.
Stair climbing should be limited to one flight/day for the first week at home. Coitus is
safe as soon as the patient's lochia has turned to alba and, if present, an episiotomy is
healed. The patient should notify the primary care provider if there is an increase, not a
decrease, in lochial discharge.
13. A postpartum patient has a history of thrombophlebitis. What should the nurse do to
determine if the patient is developing this after delivery?
A) Assess for warmth in the legs.
B) Assess temperature every 4 hours.
C) Assess for calf redness and edema.
D) Palpate the feet for tingling or numbness.
Ans: C
Feedback:
Assess for thrombophlebitis by dorsiflexing the ankle and asking if pain occurs in the
calf region. Assess also for redness in the calf area and edema of the ankle. Warmth is
not an indication of a thrombophlebitis. Body temperature is not used to assess for
thrombophlebitis. Feet numbness and tingling are not indications of thrombophlebitis.
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14. A new mother asks if it is possible to have rooming-in with the newborn. What should
the nurse respond to this patient's request?
A) It depends on whether the patient plans to breastfeed.
B) Rooming-in allows increased maternal–newborn contact.
C) This puts too much responsibility on a first-time mother.
D) Resting for the first 3 days postpartum will be better for the patient.
Ans: B
Feedback:
The more time a woman has to spend with her baby, the sooner she can become better
acquainted with her child, feel more confident in her ability to care for her baby, and
more likely form a sound mother–child relationship. Rooming-in is when the mother
and child are together 24 hours a day. Rooming-in does not depend on whether the
patient is planning to breastfeed the infant. Rooming-in helps the new mother become
confident in abilities to care for the baby. Resting for 3 postpartum days is not
recommended.
15. The nurse is concerned that a new mother is ambivalent about the newborn and does not
participate in newborn care. What action should the nurse take to help both the mother
and newborn at this time?
A) Contact the Social Services department.
B) Schedule home care for the mother and infant.
C) Assess who is going to take care of the baby at home.
D) Ask the patient if it would be better that the baby is put up for adoption.
Ans: A
Feedback:
Some patients do not openly voice a wish to give up a child, but their actions
demonstrate they feel little attachment to their newborn. A woman who has doubts
about wanting the baby is slow to make contact, barely touching the baby even by the
time of discharge, and asking few questions about newborn care. When this happens, the
hospital social service department can be of assistance in helping the patient plan the
child's future. The nurse needs to do more than schedule home care for the mother and
infant. The nurse should consult with Social Services that will assess who is going to
care for the infant at home and find out if the patient wants to give the baby up for
adoption. This is not the nurse's role.
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16. A postpartum patient is prescribed docusate sodium (Colace) as treatment for
constipation. What should the nurse include when teaching the patient about this
medication? (Select all that apply.)
A) This medication has no adverse effects.
B) Be sure to engage in activity to aid in intestinal motility.
C) One pill should be taken after every meal for the first week.
D) This medication works the best when a high-fiber diet is consumed.
E) Take each dose of the medication with a full glass of water or juice.
Ans: B, D, E
Feedback:
Docusate sodium (Colace) is used in the postpartal period to prevent constipation. It
works by lowering the surface tension of feces, allowing water and lipids to penetrate
the stool and soften it. The nurse should instruct the patient to engage in activity to
promote intestinal motility, consume a diet high in fiber, and take each dose of the
medication with a full glass of water or juice. This medication has abdominal pain and
diarrhea as potential adverse effects. This medication is not taken after every meal but
rather one dose per day.
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Chapter 18 Nursing Care of a Family With a Newborn
1. When caring for a newborn several hours after birth, what would the nurse assess as a
normal newborn's respiratory rate?
A) 12 to 16 breaths/min
B) 16 to 20 breaths/min
C) 20 to 30 breaths/min
D) 30 to 60 breaths/min
Ans: D
Feedback:
The respiratory rate of a newborn in the first few minutes of life may be as high as 80
breaths/min. Because respiratory activity is established and maintained over the next
hour, this rate will settle to an average of 30 to 60 breaths/min. Respiration rates less
than 30 breaths/min should be reported to the health care provider for evaluation.
2. The nurse is assessing a term newborn. Which finding should the nurse expect when
assessing the patterns of sole creases?
A) Creases on two thirds of the foot
B) Heel creases but no anterior creases
C) Longitudinal but no horizontal creases
D) Creases covering one fourth of the foot
Ans: A
Feedback:
The foot of a term newborn has many crisscrossed lines on the sole, covering
approximately two thirds of the foot. If these creases cover less than two thirds of the
foot or are absent, it suggests the infant is preterm.
3. During a home visit, a new mother is concerned that, after three meconium stools, her
newborn has had a bright green stool. What should the nurse explain to the mother?
A) This is a normal finding.
B) This is most likely a symptom of diarrhea.
C) The baby may be developing an allergy to breast milk.
D) The child will need to be isolated until the stool can be cultured.
Ans: A
Feedback:
After meconium stools, the newborn's stool changes in color and consistency. This is a
transitional stool and is green. It might look like diarrhea. This does not indicate that the
baby is developing an allergy to breast milk or that the child needs to be isolated until
the stool can be cultured.
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4. The nurse is planning to instruct a new mother on care of the newborn. Which
instructions support the 2020 National Health Goals for the newborn? (Select all that
apply.)
A) Place the infant on the back to sleep.
B) Wash the baby's hair at least once a week.
C) Continue to breastfeed the baby until age 6 months.
D) Bath the baby from the most soiled to the cleanest areas.
E) Do not provide the baby with a bottle while falling asleep.
Ans: A, C, E
Feedback:
Nurses can help achieve 2020 National Health Goals by encouraging mothers to
continue breastfeeding through the first 6 months of life. The mother should be
instructed to place the infants on the back to sleep and the danger of tooth decay from
allowing a baby to drink from a bottle of milk or juice while falling asleep. Bathing
should be from the most clean to the most soiled and hair should be washed daily.
Bathing and hair washing do not impact achievement of the 2020 National Health
Goals.
5. The nurse is caring for a newborn that weighed 7 lb 3 oz at birth. What action should the
nurse take first based on this weight?
A) Plot the weight on a gestational age graph.
B) Ask for a physician to examine the newborn.
C) Draw additional blood work for cholesterol level.
D) Turn off the radiant heat warmer for physical assessment.
Ans: A
Feedback:
A newborn's weight is important because it helps to determine maturity as well as
establish a baseline against which all other weights can be compared. The birth weight
of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors
that were present during conception and pregnancy. The weight in relation to the
gestational age should be plotted on a standard neonatal graph. The nurse does not need
to ask a physician to examine the newborn. There is no evidence to suggest that the
infant needs a cholesterol level drawn. The weight does not influence if the newborn
needs to be placed in a radiant heat warmer.
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6. The nurse documents that a newborn has a normal head-to-body proportion. What did
the nurse document in the baby's medical record?
A) Head one half of total length
B) Head one sixth of total length
C) Head one fourth of total length
D) Head one eighth of total length
Ans: C
Feedback:
A newborn's head usually appears disproportionately large because it is about one fourth
of the total body length. The newborn's head is not one half, one sixth, or one eighth of
the total body length.
7. The nurse completes a physical assessment of a newborn. Which finding should the
nurse identify as being abnormal?
A) Abdomen slightly protuberant
B) Clear drainage at the base of the umbilical cord
C) Bowel sounds present at two to three per minute
D) Liver palpable 2 cm under the right costal margin
Ans: B
Feedback:
The base of the cord should not appear wet. A moist or odorous cord can indicate an
infection or a patent urachus that will drain urine at the cord site until it is surgically
repaired. Normal newborn abdominal assessment findings include slightly protuberant
in shape, presence of bowel sounds, and 2 cm of the liver palpable under the right costal
margin.
8. Which assessment finding indicates to the nurse that a newborn has hip subluxation?
A) Inward rotation of the right foot
B) Inability of the right hip to abduct
C) Crying on straightening of the right leg
D) Drawing of the legs underneath while prone
Ans: B
Feedback:
If the hip joint seems to lock short of this distance of 180 degrees, hip subluxation is
suggested. Inward rotation of the right foot, crying when straightening the leg, or
drawing the legs underneath when prone does not indicate hip subluxation.
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9. The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid
when conducting this assessment?
A) Inspecting the genital area for irritated skin
B) Inspecting if the urethral opening appears circular
C) Palpating if testes are descended into the scrotal sac
D) Retracting the foreskin over the glans to assess for secretions
Ans: D
Feedback:
In most male newborns, the foreskin slides back poorly from the meatal opening, so the
nurse should not try to retract it. The nurse should inspect the area for irritated skin,
inspect the urethral opening, and palpate the testes in the scrotal sac.
10. The parents of a newborn are concerned that something is wrong with the newborn's
eyesight. What should the nurse instruct the parents as being an expected finding in the
newborn?
A) Produces tears when he cries
B) Follows a light to the midline
C) Has a white rather than a red reflex
D) Follows the finger a full 180 degrees
Ans: B
Feedback:
Instruct parents that the newborn cannot follow an object past the midline or appears to
lose track of objects easily so there is nothing wrong with the eyesight. The newborn
will not produce tears because the lacrimal ducts are not fully functioning. The parents
will not be able to assess for a red reflex. The infant will not be able to follow a finger
for a full 180 degrees.
11. A new mother is distraught because the baby has a white discharge coming from the
breasts. What should the nurse explain to the mother about this discharge?
A) It is caused by exposure to cool air.
B) It is caused by the mother's hormones.
C) The baby may need chromosomal studies.
D) It is a sign that the baby has a pituitary tumor.
Ans: B
Feedback:
In both female and male infants, the breasts may be engorged because of the influence
of maternal hormones during pregnancy. At times, the breasts of newborn babies secrete
a thin, watery fluid termed witch's milk. As soon as the hormones are cleared from the
infant's system in about a week, the engorgement and any fluid that is present will
subside. The discharge from the baby's breasts is not caused by exposure to cold air. The
baby does not need chromosomal studies nor is this a sign that the baby has a pituitary
tumor.
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12. The nurse assesses a newborn's Apgar score at birth and documents that it is normal.
Which score did the nurse most likely record?
A) 1
B) 4
C) 8
D) 13
Ans: C
Feedback:
An Apgar score between 7 and 10 indicates that the infant scored as high as 70% to 90%
of all infants at 1 and 5 minutes after birth and is adjusting well to extrauterine life. A
score of 4 to 6 indicates a guarded condition, and the newborn may need clearing of the
airway and supplementary oxygen. A score <4 indicates serious danger of respiratory or
cardiovascular failure, and the newborn needs resuscitation. Ten is the maximum
number on the Apgar scoring system.
13. When assessing a newborn's 5-minute Apgar score, how will the nurse determine reflex
irritability?
A) Dorsiflexing a foot against pressure resistance
B) Raising the infant's head and letting it fall back
C) Tightly flexing the infant's trunk and then releasing it
D) Slapping the soles of the feet and observing the response
Ans: D
Feedback:
One of two possible cues is used to evaluate reflex irritability: response to a suction
catheter in the nostrils or response to having the soles of the feet slapped. Reflex
irritability is not assessed by dorsiflexing the foot, permitting the head to fall, or flexing
the infant's trunk and releasing it.
14. What instructions should the nurse include when teaching a mother to care for her
newborn's umbilical cord?
A) Keep it dry.
B) Cover it with dry gauze.
C) Wash it with soap and water.
D) Apply petroleum jelly to it daily.
Ans: A
Feedback:
Until the cord falls off, fold diapers below the level of the umbilical cord, so that when
the diaper becomes wet, the cord does not become wet also. Remind the mother to
continue to keep the cord dry until it falls off. The nurse should not teach the mother
cover the umbilical cord with dry gauze, wash it with soap and water, or apply
petroleum jelly to the site.
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15. A patient who has just given birth to her first baby asks the nurse for help with
breastfeeding. Which nursing diagnosis would be the most appropriate for the patient at
this time?
A) Powerlessness
B) Health-seeking behaviors
C) Readiness for enhanced coping
D) Anxiety related to breastfeeding
Ans: B
Feedback:
The new mother is asking the nurse for help with breastfeeding, which supports the
nursing diagnosis of health-seeking behaviors. The patient requesting help with
breastfeeding does not indicate powerlessness, readiness for enhanced coping, or
anxiety related to breastfeeding.
16. The nurse is visiting a new mother who has been home with a new infant for 4 days.
Which observation indicates that the mother's home environment was inadequately
assessed prior to being discharged from the hospital?
A) Baby has a changing area.
B) Kitchen has a refrigerator.
C) Windows are covered with screens.
D) Baby sleeps with the mother in bed.
Ans: D
Feedback:
Evidence that an inadequate home environment assessment was performed as baby is
sleeping with the mother. The American Academy of Pediatrics recommends newborns
have their own crib as a step toward preventing sudden infant death syndrome. The baby
having a changing area, the kitchen has a refrigerator, and the windows are covered with
screens indicate that the home environment is adequate to support the needs of a
newborn.
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17. A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg
intramuscularly. What should the nurse do when providing this medication to the
newborn?
A) Administer the medication in the deltoid muscle.
B) Administer the medication into the anterolateral muscle.
C) Provide the medication immediately before breastfeeding.
D) Notify the physician for swelling and irritation at the injection site.
Ans: B
Feedback:
Vitamin K should be administered into a large muscle such as the anterolateral muscle
of the newborn's thigh. The deltoid muscle is not used for intramuscular injections in the
newborn. The medication should be given so as not to interrupt breastfeeding. Swelling
and irritation at the injection site is a possible adverse reaction and does not necessarily
need to be reported to the physician.
18. A new mother does not want the baby to return to the nursery because of the fear of
someone taking the baby without her permission. What should the nurse explain to the
mother to allay her fears?
A) Only people who are known to the staff are permitted in the nursery.
B) Keeping the baby in the mother's room at all times is the best approach.
C) Both the mother and infant have identification bands that need to match.
D) Security questions everyone before permitting them access to the hospital.
Ans: C
Feedback:
Hospitals have an identification banding system where the mother's and the infant's
identification bands are to match. Only people with proper hospital identification should
be permitted into the nursery. Keeping the baby in the mother's room at all times could
be dangerous because the baby could be left unattended, permitting someone an
opportunity to abduct the infant. Security does not routinely question everyone before
permitting them access to the hospital.
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Chapter 19 Nutritional Needs of a Newborn
1. A pregnant patient in labor asks the nurse how soon the baby can be breastfed after
delivery. What should the nurse respond to the patient?
A) Immediately after birth
B) After the infant is allowed to rest
C) In 24 hours after her infant is given water
D) Once the infant has a first feeding of formula
Ans: A
Feedback:
Breastfeeding should begin as soon after birth as possible, ideally while the woman is
still in the birthing room and while the infant is in the first reactivity period.
Breastfeeding should not wait until the baby rests. Twenty-four hours is too long to wait
to begin breastfeeding. Mixing breastfeeding and formula feeding is not recommended.
2. The nurse is explaining the process of breast milk production with a patient pregnant
with her first child. What should the nurse include when providing this teaching? (Select
all that apply.)
A) Breast milk is thin, yellow, and watery.
B) For the first 3 to 4 days, the breast milk is colostrum.
C) Uterine cramping is a contraindication to breastfeeding.
D) True breast milk comes in by the 10th day after giving birth.
E) Most mothers have breast milk by the first day after giving birth.
Ans: B, D
Feedback:
For the first 3 to 4 days after delivery, the breast milk is colostrum. The consistency
changes to true breast milk by the 10th postpartum day. Colostrum is thin, yellow, and
watery. Uterine cramping occurs as a result of oxytocin released during breastfeeding
and is not a contraindication to breastfeeding but an expected occurrence. Most mothers
do not have breast milk by the first day after giving birth.
3. During a home visit, the nurse learns that a new mother is experiencing breast
engorgement. What should the nurse recommend to help alleviate this problem?
A) Discontinuing breastfeeding for 24 hours
B) Having her apply lanolin cream to each breast
C) Encouraging her to continue regular breastfeeding
D) Decreasing her fluid intake to below 500 ml per 24 hours
Ans: C
Feedback:
A common suggestion to relieve breast engorgement is to empty the breasts of milk by
having the infant suck more often or at least continue to suck as much as before.
Breastfeeding should not be discontinued. Applying cream to the breasts will not help
with engorgement. The mother does not need to be placed on a fluid restriction.
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4. A new mother is ambivalent about breastfeeding and agrees to do it for at least 3
months. What response should the nurse provide to the patient at this time that would
support the 2020 National Health Goals?
A) Breastfeeding helps the mother return to prepregnancy weight faster.
B) Three months is the recommended time frame for the baby's nutrition.
C) Breast milk can be donated so that preterm infants can have additional nutrition.
D) Six months to 1 year of age is the best time frame to support the baby's growth
needs.
Ans: D
Feedback:
Six months to 1 year of age is one of the 2020 National Health Goals for breastfeeding.
Although breastfeeding can help the mother return to prepregnancy weight, this is not a
2020 National Health Goal for breastfeeding. Three months is not the recommended
time frame for the baby's nutrition. Breast milk can be donated; however, this is not a
2020 National Health Goal for breastfeeding.
5. A new mother is concerned that the baby is not going to receive enough calories from
breast milk to grow. What should the nurse instruct the mother as the daily caloric
requirements per pound of weight for a newborn?
A) 50 to 55
B) 100 to 120
C) 150 to 170
D) 200 to 225
Ans: A
Feedback:
An infant up to 2 months of age requires 110 to 120 calories per kilogram of body
weight or 50 to 55 kcal/lb every 24 hours to provide an adequate amount for
maintenance and growth. The other choices are incorrect information.
6. The nurse is teaching a pregnant patient about the nutritional value of breast milk. What
information should the nurse include about the number of calories in a fluid ounce?
A) 12
B) 20
C) 24
D) 30
Ans: B
Feedback:
Breast milk contains 20 calories per fluid ounce, which is the same number of calories
in commercially prepared infant formula. Breast milk does not contain 12, 24, or 30
calories per fluid ounce.
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7. A pregnant patient had decided to breastfeed the infant but, after delivery, tells the nurse
that formula feeding would be the best choice for her now. What nursing diagnosis
should the nurse use to plan this patient's care?
A) Anxiety
B) Ineffective coping
C) Imbalanced nutrition
D) Risk for impaired parenting
Ans: D
Feedback:
The mother has decided to forgo breastfeeding for formula feeding. This decision could
place the mother at risk for impaired parenting because of the need to formula feed the
infant. The mother's decision does not support the diagnoses of anxiety and ineffective
coping. It is unlikely that the infant will have imbalanced nutrition related to formula
feeding.
8. The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria
indicate that the mother is able to breastfeed independently? (Select all that apply.)
A) Nipples are everted.
B) Breasts are soft and nontender.
C) Mother holds the nipple in the baby's mouth.
D) Baby swallows spontaneously and frequently.
E) Nurse places pillows under the baby for support.
Ans: A, B, D
Feedback:
The LATCH breastfeeding charting system is used to measure a mother's ability to
breastfeed independently. Criteria that indicate the mother can breastfeed independently
include everted nipples, breasts are soft and nontender, and the baby swallows
spontaneously and frequently. The mother having to hold the nipple in the baby's mouth
and the nurse assisting with positioning indicate the mother is not independent in
breastfeeding.
9. The nurse is preparing a seminar on breastfeeding for a group of pregnant patients.
Which information should the nurse include during this seminar?
A) Uterine involution is slowed by breastfeeding.
B) Breastfeeding enhances bonding with the infant.
C) Breastfeeding might increase the risk of breast cancer.
D) Breastfeeding mothers have a decreased risk of developing thrombophlebitis.
Ans: B
Feedback:
Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond
between mother and child. Breastfeeding enhances uterine involution and reduces the
risk of breast cancer. There is no information to support the impact of breastfeeding on
thrombophlebitis.
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10. A new mother asks the nurse to explain the difference between breastfeeding and
formula when feeding a newborn. What should the nurse respond as an advantage of
breastfeeding for the infant?
A) Breast milk leads to firmer stools, increasing bowel tone.
B) It takes less effort for an infant to suck at a breast than from a bottle.
C) Breast milk is more difficult to digest, so it makes the infant feel fuller longer.
D) Breast milk contains antibodies and decreases the possibility of gastrointestinal
illnesses.
Ans: D
Feedback:
Breast milk contains secretory immunoglobulin A (IgA), which binds large molecules of
foreign proteins, including viruses and bacteria, keeping them from being absorbed from
the gastrointestinal tract. Breast milk does not cause firmer stools. It takes more effort
for the infant to suck at a breast than at a bottle. Breast milk is less difficult for the baby
to digest.
11. A new mother is concerned that she will not have enough breast milk because of small
breasts. What should the nurse respond to the mother?
A) “Have you discussed this concern with your physician?”
B) “The size of breasts does not impact the amount of breast milk that is made.”
C) “The baby's diet can be supplemented with formula beginning on the second day.”
D) “No woman has to worry about milk production as long as she feeds the baby
frequently.”
Ans: B
Feedback:
Breast milk is formed in the acinar cells of the mammary glands and begins production
after the delivery of the placenta. When the progesterone level falls, the production of
prolactin is stimulated, which cause breast milk to be made. The nurse can discuss the
patient's concern; it does not need to be discussed with the physician. Supplementing a
breastfeeding baby with formula is not recommended. The nurse's comment about milk
production and the frequency of feeding does not address the mother's concern.
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12. The nurse is assisting a new mother begin breastfeeding. Which action is the most
appropriate for the nurse to take at this time?
A) Positioning the infant near her breast and stroking his cheek to encourage him to
suck
B) Stressing that breastfeeding is a normal process and will need minimal help
learning it
C) Cautioning her not to allow the infant to grasp the areola of her breast to prevent
soreness
D) Encouraging her to lie on her side and help the baby become wide awake by
talking to him
Ans: D
Feedback:
When a mother is first attempting to breastfeed, lying on the side with a pillow under
the head is a good position to use because it relieves fatigue and allows the infant to rest
on the bed and not on the mother. Stroking the cheek will cause the infant to turn away
from the breast. Infants should grasp the nipple areola with the mouth. Most new
mothers need some instruction and help.
13. During a home visit, a new mother tells the nurse that her nipples are sore from
breastfeeding. What should the nurse instruct the mother at this time? (Select all that
apply.)
A) Insert plastic liners into the nursing bra.
B) Apply lanolin to nipples after air exposure.
C) Expose the nipples to air so the nipple dries.
D) Position the baby differently for each feeding.
E) Massage a few drops of breast milk to the areola.
Ans: B, C, D, E
Feedback:
To help with sore nipples from breastfeeding, the nurse should instruct the mother to
apply lanolin to nipples after air exposure, expose the nipples to air so the nipple dries,
position the baby differently for each feeding, and massage a few drops of breast milk to
the areola. The mother should be discouraged from inserting plastic liners into the
nursing bra because these prevent air from circulating around the breast.
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14. A new mother asks the nurse how to determine if the baby is receiving enough breast
milk. What response should the nurse make to the mother?
A) “The infant should not become constipated.”
B) “The infant should sleep at least 3 hours between feedings.”
C) “You need to weigh the infant before and after each feeding.”
D) “The infant should gain weight and have six wet diapers daily.”
Ans: D
Feedback:
Acceptable criteria during the first week of life are wetting six to eight diapers within 24
hours or losing no more than 10% of birth weight. After the first week, weight gain and
voiding six to eight times each 24 hours are good criteria to use. The infant will not
become constipated when ingesting breast milk. Sleeping is individual for each baby
and cannot be used to determine an adequate nutritional intake. Weighing the infant
before and after feedings is not recommended.
15. A new mother asks the nurse what medications she can and cannot take into her body
because it might affect breast milk. What should the nurse respond to this mother's
request?
A) Almost all drugs are excreted to some extent in breast milk.
B) A mother should halt breastfeeding for 1 week after taking any drug.
C) A mother can plan on taking common over-the-counter drugs without difficulty.
D) A mother has to limit her exposure to narcotics and sedatives while breastfeeding.
Ans: A
Feedback:
Almost any drug may cross into the acinar cells and be secreted in breast milk. As a
general rule, the mother should take no drug unless prescribed or approved by her
primary care provider while breastfeeding. Halting breastfeeding could impact the
mother's ability to continue at a later time.
16. During a routine health visit, the mother of a 6-month-old baby mentions that she would
like to begin weaning the baby from breastfeeding. What teaching should the nurse
provide to the mother at this time?
A) Apply heat to the breasts to suppress breast milk production.
B) Discontinue gradually by omitting one breastfeeding session a day.
C) Instead of breastfeeding the baby, pump the breasts to reduce pressure.
D) Provide a bottle of regular milk to supplement one breastfeeding session.
Ans: B
Feedback:
When weaning, breastfeeding should be discontinued gradually by first omitting one
breastfeeding a day and substituting a formula feeding. Heat to the breasts does not
suppress milk production. Pumping the breasts will continue milk production. If
weaning before 12 months, the baby should be weaned to formula and not whole milk.
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17. The nurse is teaching new parents how to calculate the amount of formula to feed their
newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the
parents to provide each day?
A) 20 to 24 oz
B) 30 to 36 oz
C) 42 to 54 oz
D) 60 to 72 oz
Ans: A
Feedback:
The total fluid ingested for 24 hours must be sufficient to meet the infant's fluid needs
and is calculated by determining 75 to 90 ml or 2.5 to 3.0 oz of fluid per pound of body
weight per day. Because the infant weighs 8 lb, the amount of formula would be
between 8.0 × 2.5 or 20 oz and 8.0 × 3.0 or 24 oz. The other choices are inaccurate
calculations for the amount of formula to provide to an infant weighing 8 lb.
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Chapter 20 Nursing Care of a Family Experiencing a Pregnancy Complication
From a Preexisting
1. A patient with asthma who is 32 weeks pregnant is concerned that the health care
provider has reduced the doses of asthma maintenance medications. What should the
nurse respond to this patient's concern?
A) Asthma medication is teratogenic and should not be taken.
B) Asthma improves during pregnancy so higher doses are not needed.
C) Asthma medication may reduce labor contractions and should be reduced.
D) Asthma medication is ineffective during pregnancy and should be stopped.
Ans: C
Feedback:
Some asthma maintenance medication such as beta-adrenergic agonists may be taken
safely during pregnancy, but they have the potential to reduce labor contractions. The
doses of these medications may be reduced as the patient approaches the time of
delivery. Not all asthma medication is teratogenic. Asthma can improve during
pregnancy because of circulating corticosteroids; however, the doses of the medications
should have already been adjusted according to the patient's symptoms. There is no
evidence to support that asthma medication is ineffective during pregnancy.
2. A patient with type 2 diabetes mellitus is planning to become pregnant within the next
several months. What should the nurse instruct the patient to support the 2020 National
Health Goals of reducing the complications of pregnancy from diabetes?
A) Avoid episodes of hyperglycemia.
B) Reduce the current exercise regimen by half.
C) Limit the intake of carbohydrates and fats in the diet.
D) Reduce the use of insulin for blood glucose coverage.
Ans: A
Feedback:
To support the 2020 National Health Goals, the nurse should instruct the patient to enter
pregnancy without hyperglycemia. This action helps reduce congenital anomalies in
newborns. Reducing exercise, limiting carbohydrates and fats, and reducing the use of
insulin for blood glucose coverage does not support the 2020 National Health Goals to
reduce the complications of pregnancy associated with diabetes.
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3. A patient with diabetes is in the first trimester of pregnancy and is currently having
difficulty keeping blood glucose levels within normal limits. The patient explains that
she has been “eating for two” so the baby is healthy. What should the nurse respond to
the patient?
A) “Elevated blood glucose levels cause low birth weights in infants.”
B) “Elevated blood glucose levels ensure the baby has mature lungs at birth.”
C) “Elevated blood glucose levels hasten the development of the fetus in utero.”
D) “Elevated blood glucose levels in the first trimester have been linked to congenital
anomalies.”
Ans: D
Feedback:
The first trimester of pregnancy is the most important time for fetal development. If the
patient can control hyperglycemia during this time, the chances of a congenital anomaly
are greatly reduced. Infants of patients with poorly controlled diabetes tend to be large.
At birth, babies born to patients with uncontrolled diabetes are prone to respiratory
distress syndrome. Elevated blood glucose levels do not hasten the development of the
fetus in utero and can lead to hydramnios.
4. The nurse determines that a pregnant patient is at risk for developing a deep vein
thrombosis. What should the nurse instruct the patient to reduce the risk of this potential
complication? (Select all that apply.)
A) Avoid foods high in calcium.
B) Take a baby aspirin every day.
C) Avoid standing in one position.
D) Do not cross the legs at the knee.
E) Do not wear knee-high stockings.
Ans: C, D, E
Feedback:
The risk of thrombus formation can be reduced through measures such as avoiding the
use of constrictive knee-high stockings, not sitting with legs crossed at the knee, and
avoiding standing in one position for a long period. Calcium restriction does not reduce
the risk of thrombus formation and could potentially harm the developing fetus. The
nurse cannot prescribe medication, and the patient should not take any medication
without direction from the health care provider.
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5. A patient with diabetes who is in the second trimester of pregnancy notes that the usual
dose of insulin to maintain blood glucose levels has been increasing over the last few
weeks. What should the nurse explain to the patient about insulin during pregnancy?
A) The fetus is using insulin to maintain blood glucose level in utero.
B) Insulin resistance develops because of placenta and other hormones.
C) An increase in circulating blood volume during pregnancy deactivates insulin.
D) The change in diet causes an increased need for insulin to maintain blood glucose
levels.
Ans: B
Feedback:
Patients with diabetes, who become pregnant, develop insulin resistance as the
pregnancy progresses, or insulin does not seem as effective during pregnancy. This
phenomenon is believed to be caused by the presence of the hormone human placental
lactogen and high levels of cortisol, estrogen, progesterone, and catecholamines. The
increased need for insulin is not because of the fetus using insulin to maintain blood
glucose level in utero. The patient's increased circulating blood volume is not
deactivating insulin. The patient's change in diet might necessitate an adjustment in
insulin dosage, but this would vary according to blood glucose level.
6. A patient with heart disease who is 28 weeks pregnant asks the nurse why office
appointments have been scheduled every week for the next 4 weeks. What should the
nurse respond to the patient?
A) This is the routine schedule for all pregnant patients.
B) This is when most patients have a risk of going into early labor.
C) During weeks 28 and 32, blood volume peaks, and heart function can be affected.
D) Extra care is needed to make sure the fetus is developing normally during this
time period.
Ans: C
Feedback:
The danger of pregnancy in a patient with heart disease occurs primarily because of this
increase in circulatory volume. The most dangerous time for the patient is in weeks 28
to 32, just after the blood volume peaks. Weekly appointments are not routine for all
pregnant patients at this part of the pregnancy. This is not the time when most patients
have a risk of going into early labor. The extra appointments are not needed to make
sure the fetus is developing normally during this time period.
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7. The nurse is preparing to instruct a pregnant patient with a history of tuberculosis on
care needed while pregnant. What should the nurse include when teaching this patient?
A) Maintain a high vitamin C intake.
B) Maintain a high intake of calcium.
C) Be prepared to have the child by cesarean birth.
D) Avoid contracting an upper respiratory infection.
Ans: B
Feedback:
A patient who had tuberculosis earlier in life must be especially careful to maintain an
adequate level of calcium during pregnancy to ensure the calcium tuberculosis pockets
in the lungs are not broken down and the disease reactivated. A high vitamin C intake is
not indicated for this patient's health history. Pushing during labor might cause calcified
tuberculosis pockets in the lungs to break, but this does not mean that all patients with a
history of tuberculosis have to have cesarean deliveries. All pregnant patients should be
instructed to avoid upper respiratory infections.
8. The nurse is caring for a patient who desires to become pregnant within a few months.
Which outcome regarding folic acid intake would be appropriate for this patient?
A) The client will begin taking 400 g of folic acid every day.
B) The client will begin taking 400 g of folic acid with every meal.
C) The client will ingest foods high in folic acid to avoid needing to take folic acid
supplements.
D) The client will begin taking 400 g of folic acid immediately after confirmation of
pregnancy.
Ans: A
Feedback:
All patients expecting to become pregnant are advised to begin a supplement of 400 g
folic acid daily in addition to eating foods rich in folic acid. The folic acid supplement is
not needed with each meal. Foods high in folic acid should be consumed in addition to
the supplement. The patient should take folic acid supplements before becoming
pregnant and not wait until pregnancy is confirmed.
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9. A patient who is 36 weeks pregnant has been taking phenytoin (Dilantin) for a seizure
disorder. Which supplement should the nurse anticipate being prescribed for this
patient?
A) Vitamin C
B) Vitamin D
C) Vitamin E
D) Vitamin K
Ans: D
Feedback:
Phenytoin (Dilantin) is believed to cause a fetal syndrome that includes vitamin K
deficiency. To counteract the vitamin K deficiency and prevent hemorrhage in the
newborn, the patient may be prescribed vitamin K during the last 4 weeks of gestation.
Vitamins C, D, or E have no impact on the pregnant patient who is taking phenytoin
(Dilantin) for a seizure disorder.
10. The nurse instructs a pregnant patient with sickle-cell anemia on ways to prevent a
crisis. Which patient statement indicates that teaching has been effective?
A) “I should drink eight glasses of water every day.”
B) “I should take an iron supplement every day.”
C) “I should make sure I stand for at least 4 hours every day.”
D) “I should avoid sitting with my legs elevated during the day.”
Ans: A
Feedback:
The fluid status of a pregnant patient with sickle-cell anemia is important because
dehydration can precipitate a crisis. The patient should drink at least eight glasses of
fluid each day to prevent dehydration. Patients with sickle-cell anemia should not take
an iron supplement because the sickled cells cannot incorporate iron in the same way as
nonsickled cells. Standing for long periods of time can cause red cell destruction in the
patient with sickle-cell anemia. The patient should sit with the legs elevated to
encourage venous return of blood from the lower extremities.
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11. The nurse is reviewing medication orders for a pregnant patient diagnosed with a
urinary tract infection. Which medication order should the nurse question for this
patient?
A) Ampicillin
B) Amoxicillin
C) Tetracycline
D) Cephalosporin
Ans: C
Feedback:
Amoxicillin, ampicillin, and cephalosporins are effective against most organisms
causing UTIs and are safe antibiotics during pregnancy. Tetracyclines are
contraindicated during pregnancy because they cause retardation of bone growth and
staining of the fetal teeth.
12. A postpartum patient with systemic lupus erythematosus asks why symptoms of the
disease are worse now that the baby has been born. What should the nurse explain to the
patient?
A) The fetus was keeping the symptoms in check.
B) The stress of delivery causes the symptoms to increase.
C) A spike in maternal hormone levels causes an increase in symptoms.
D) Symptoms may be worse because corticosteroid levels are returning to normal.
Ans: D
Feedback:
During the postpartum period, there may be an acute exacerbation of systemic lupus
erythematosus symptoms because corticosteroid levels are returning to normal.
Symptoms are not increased because the fetus was keeping the symptoms in check. The
stress of delivery is not causing the symptoms to increase. The symptoms are not
because of a spike in maternal hormone levels.
13. A pregnant patient is diagnosed with hyperthyroidism. For which medication should the
nurse prepare teaching for this patient?
A) Methimazole
B) Cephalosporin
C) Levothyroxine
D) Propylthiouracil
Ans: A
Feedback:
Methimazole is the preferred drug to treat pregnant patients with hyperthyroidism
because it appears to cross the placenta less easily. Propylthiouracil crosses the placenta
and can lead to congenital hypothyroidism and an enlarged thyroid gland in the fetus.
Cephalosporin is an antibiotic that is not used in the treatment of hyperthyroidism.
Levothyroxine is thyroid hormone and is used in the treatment of hypothyroidism.
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14. The nurse is designing a plan of care for a pregnant patient with inflammatory bowel
disease. What should be included in this patient's plan? (Select all that apply.)
A) Instruct on the need for early cesarean birth.
B) Carefully measure the patient's weight with each prenatal visit.
C) Suggest fluids and oral food intake be restricted to rest the bowel.
D) Explain the need for gamma globulin injections during the last trimester.
E) Ensure that the patient is taking anti-inflammatory medication as prescribed.
Ans: B, E
Feedback:
Because of the potential difficulty with absorbing nutrients, the pregnant patient with
inflammatory bowel disease needs careful monitoring for weight gain during pregnancy.
Anti-inflammatory medication may be continued during pregnancy without fetal injury.
The patient does not need a cesarean birth for this health problem. Foods and fluids
should not be restricted because the patient has difficulty absorbing nutrients anyway.
Gamma globulin injections are not indicated for this disorder
15. A patient in the second trimester of pregnancy is diagnosed with cervical cancer. For
which treatment should the nurse instruct the patient as causing the least harm to the
developing fetal?
A) Chemotherapy
B) Chelation therapy
C) Radiation therapy
D) Anticoagulant therapy
Ans: A
Feedback:
As a rule, patients can receive chemotherapy in the second and third trimesters without
adverse fetal effects. Radiation therapy puts the fetus at risk throughout pregnancy if the
fetus is directly exposed. Chelation and anticoagulants are not therapies associated with
cancer treatment.
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Chapter 21 Nursing Care of a Family Experiencing a Sudden Pregnancy Complication
1. A pregnant patient is diagnosed with placenta previa. Which action should the nurse
implement immediately for this patient?
A) Assess fetal heart sounds with an external monitor.
B) Help the patient remain ambulatory to reduce bleeding.
C) Assess uterine contractions by an internal pressure gauge.
D) Prepare for a vaginal examination to assess the extent of bleeding.
Ans: A
Feedback:
For placenta previa, the nurse should attach external monitoring equipment to record
fetal heart sounds and uterine contractions. Internal pressure gauges to measure uterine
contractions are contraindicated. A pelvic or rectal examination should never be done
with painless bleeding late in pregnancy because any agitation of the cervix when there
is a placenta previa might tear the placenta further and initiate massive hemorrhage,
which could be fatal to both mother and child. To ensure an adequate blood supply to
the patient and fetus, the patient should be placed immediately on bed rest in a
side-lying position.
2. The nurse is preparing an education session on the 2020 National Health Goals to
prevent complications of pregnancy. What should the nurse include as the best
preventive measure to eliminate complications of pregnancy?
A) Encourage all pregnant patients to have prenatal care.
B) Suggest all pregnant patients keep weight gain to a minimum.
C) Recommend all pregnant patients engage in exercise most days of the week.
D) Counsel all pregnant patients to select low-fat dairy products rich in calcium.
Ans: A
Feedback:
Encouraging all women to come for prenatal care is the best preventive measure for
eliminating complications of pregnancy. Weight gain, exercise, and calcium intake are
not identified as specific measures to prevent complications of pregnancy.
3. The nurse is concerned that a pregnant patient is experiencing abruptio placentae. What
did the nurse assess in this patient?
A) Increased blood pressure and oliguria
B) Pain in a lower quadrant and increased pulse rate
C) Painless vaginal bleeding and a fall in blood pressure
D) Sharp fundal pain and discomfort between contractions
Ans: D
Feedback:
Abruptio placentae is characterized by a sharp, stabbing pain high in the uterine fundus
as the initial separation occurs. Manifestations of abruptio placentae do not include
increased blood pressure, oliguria, pain in the lower quadrant, increased pule rate,
painless vaginal bleeding, or a fall in blood pressure.
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4. A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood
clots and dark red blood from the vagina. What should the nurse direct the patient to do
at this time?
A) Begin immediate bed rest.
B) Count the number of perineal pads that are saturated with blood.
C) Continue with normal daily activity and monitor pulse rate every hour.
D) Seek immediate medical attention and bring the expressed vaginal material.
Ans: D
Feedback:
Gestational trophoblastic disease is abnormal proliferation and then degeneration of the
trophoblastic villi. The embryo fails to develop beyond a primitive start. At
approximately week 16 of pregnancy, vaginal bleeding will begin as spotting of
dark-brown blood accompanied by discharge of the clear fluid-filled vesicles. The
pregnant patient who begins to miscarry at home needs to bring any clots or tissue
passed to the hospital because the presence of clear fluid-filled cysts identifies
gestational trophoblastic disease. The patient needs to seek immediate medical attention
and not stay at home on bed rest, count perineal pads, or continue with normal activity
and count pulse rates every hour.
5. The nurse is reviewing the plan of care for a pregnant patient experiencing a threatened
miscarriage. Which outcome would be appropriate for this patient?
A) Bed rest is maintained until all bleeding stops.
B) Less than one perineal pad is saturated per hour.
C) Bleeding spontaneously stops within 24 to 48 hours.
D) Normal coitus is resumed 1 week after the episode.
Ans: C
Feedback:
For a threatened miscarriage, an outcome for care would be that all bleeding would
spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened
miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a
perineal pad in 1 hour is an emergency and could indicate an incomplete or complete
miscarriage. Normal coitus should be withheld for 2 weeks after a threatened
miscarriage.
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6. A pregnant patient with a history of premature cervical dilatation undergoes cervical
cerclage. Which outcome indicates that this procedure has been successful?
A) The client delivers a full-term fetus at 39 weeks' gestation.
B) The client's membranes spontaneously rupture at week 30 of gestation.
C) The client experiences minimal vaginal bleeding throughout the pregnancy.
D) The client has reduced shortness of breath and abdominal pain during the
pregnancy.
Ans: A
Feedback:
Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a
fetus until term. After the loss of one child because of premature cervical dilatation, a
surgical operation termed cervical cerclage can be performed to prevent this from
happening in a second pregnancy. This procedure is the use of purse-string sutures
placed in the cervix to strengthen the cervix and prevent it from dilating until the end of
pregnancy. Evidence that this procedure is effective would be the client delivering a
full-term fetus at 39 weeks' gestation. Spontaneous rupture of the membranes could
indicate that the procedure was not successful. Vaginal bleeding could indicate another
health problem or that the procedure was not successful. This procedure does not impact
the patient's respirations or amount of abdominal pain while pregnant. These
manifestations could indicate another health problem with the pregnancy.
7. A patient recovering from an uneventful vaginal delivery is prescribed Rh (D) immune
globulin (RhIG). What should the nurse explain to the patient regarding the purpose of
this medication?
A) It prevents fetal Rh blood formation.
B) It stimulates maternal D immune antigens.
C) It prevents maternal D antibody formation.
D) It promotes maternal D antibody formation.
Ans: C
Feedback:
Rh (D) immune globulin (RhIG) is given to Rh-negative pregnant patients to prevent the
formation of maternal antibodies to the Rh-positive blood type of the developing fetus.
This medication does not prevent fetal Rh blood formation, stimulate maternal immune
antigens, or promote maternal antibody formation.
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8. A pregnant patient is diagnosed with preterm labor. What should the nurse teach the
patient to help prevent the reoccurrence of preterm labor? (Select all that apply.)
A) Drink 8 to 10 glasses of fluid each day.
B) Report any signs of ruptured membranes.
C) Remain on bed rest except to use the bathroom.
D) Lie flat on the back should uterine contractions occur.
E) Engage in mild activities of daily living with frequent rest periods.
Ans: A, B, C
Feedback:
To reduce the onset of preterm labor, the nurse should instruct the patient to drink 8 to
10 glasses of fluid each day to remain hydrated. The patient should also report any signs
of ruptured membranes and remain on bed rest unless using the bathroom. Should
uterine contractions begin, the patient should be instructed to lie on either the right or
left side to increase blood return to the uterus. The patient should not engage in any
activity other than bed rest with bathroom privileges.
9. The nurse is evaluating care provided to a patient in the third trimester of pregnancy
who has been diagnosed with gestational hypertension. Which finding indicates that
treatment has been successful for this patient?
A) Urine protein 0
B) Increased perspiration
C) Weight gain of 1 lb/week
D) Diastolic blood pressure 20 mmHg over normal level
Ans: A
Feedback:
Manifestations of gestational hypertension include elevated blood pressure, edema, and
proteinuria. Absence of protein in the urine indicates that treatment has been successful.
Increased perspiration is not a manifestation of gestational hypertension. A weight gain
of 1 lb/week in the patient who is in the third trimester of pregnancy is an indication of
ongoing edema. A diastolic blood pressure that is 20 mmHg over normal level is an
indication of ongoing hypertension.
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10. A pregnant patient is being admitted for severe preeclampsia. In which room location
should the nurse place this patient?
A) Near the nursery
B) Next to the elevator
C) In the back private room
D) Across from the nurse's station
Ans: C
Feedback:
With severe preeclampsia, hospitalization is required so that bed rest can be enforced
and the patient can be observed more closely. A patient with severe preeclampsia is
admitted to a private room so that rest is undisturbed. Noises such as a baby crying,
elevator doors opening and closing, and conversation from the nurse's station is
sufficient to trigger a seizure. A private room will help reduce the likelihood of seizure
development.
11. The nurse is monitoring a pregnant patient who is receiving intravenous magnesium
sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a
patellar reflex. What should the nurse do?
A) Check fetal heart rate.
B) Measure blood pressure.
C) Stop the current infusion.
D) Increase the infusion rate.
Ans: C
Feedback:
When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon
reflexes are absent. Checking the fetal heart rate and measuring blood pressure could
waste time and provide the patient with more magnesium sulfate. The infusion rate
should not be increased because this could lead to cardiac dysrhythmias and respiratory
depression.
12. The nurse is identifying nursing diagnoses for a patient with gestational hypertension.
Which diagnosis would be the most appropriate for this patient?
A) Risk for injury related to fetal distress
B) Imbalanced nutrition related to decreased sodium levels
C) Ineffective tissue perfusion related to poor heart contraction
D) Ineffective tissue perfusion related to vasoconstriction of blood vessels
Ans: D
Feedback:
In gestational hypertension, vasospasm occurs in both small and large arteries during
pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest
that the fetus is in distress. There is no enough information to support imbalanced
nutrition. Gestational hypertension does not affect heart contractions.
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13. A pregnant patient is developing HELLP syndrome. During labor, which order should
the nurse question?
A) Assess urine output every hour.
B) Prepare for epidural anesthesia.
C) Position on the left side during labor.
D) Assess blood pressure every 15 minutes.
Ans: B
Feedback:
In the HELLP syndrome, patients develop low platelet counts. With a low platelet
count, injections such as epidural anesthesia are contraindicated. This is the order that
the nurse should question. The patient's urine output should be assessed every hour
because renal failure is a complication of this syndrome. Positioning on the left side
during labor will help blood flow to the uterus. Assessing blood pressure every 15
minutes is appropriate for the patient with this syndrome.
14. A patient is admitted with a diagnosis of ectopic pregnancy. For what should the nurse
anticipate preparing the patient?
A) Immediate surgery
B) Internal uterine monitoring
C) Bed rest for the next 4 weeks
D) Intravenous administration of a tocolytic
Ans: A
Feedback:
An ectopic pregnancy is one in which implantation occurred outside the uterine cavity,
usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture.
The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels
and to remove or repair the damaged fallopian tube. There is no reason to begin uterine
monitoring. The patient does not need to be on bed rest for 4 weeks. A tocolytic is not
needed because the patient is not in labor.
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15. The nurse is preparing discharge instructions for a pregnant patient experiencing
preterm rupture of membranes. What should the nurse include in this teaching? (Select
all that apply.)
A) Avoid douching.
B) Resume regular coitus.
C) Take a tub bath at least once per day.
D) Expect malodorous vaginal discharge.
E) Measure oral temperature twice a day.
Ans: A, E
Feedback:
The patient with premature rupture of membranes is at risk for developing an infection.
The nurse should instruct the patient to avoid douching and measure oral temperature
twice a day. Coitus and tub baths should be avoided because these could introduce an
infection into the uterus. A malodorous vaginal discharge could indicate infection and
should be reported to the health care provider.
16. The nurse is concerned that a pregnant patient is developing hydramnios. What did the
nurse assess in this patient? (Select all that apply.)
A) Tense uterus
B) Sudden weight loss
C) Extreme shortness of breath
D) Difficulty hearing fetal heart rate
E) Uterus larger than expected for gestation week
Ans: A, C, D, E
Feedback:
Hydramnios is an excessive amount of amniotic fluid. The first sign of this disorder may
be a rapid enlargement of the uterus. The uterus becomes tense, and the patient
experiences shortness of breath because of the uterus pressing on the diaphragm.
Auscultating the fetal heart rate can be difficult because of depth of the increased
amount of fluid surrounding the fetus. The uterus will be larger than expected for the
patient's gestational week.
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Chapter 22 Nursing Care of a Pregnant Family With Special Needs
1. The nurse is planning an education session for pregnant adolescents. Which topics
should the nurse include that incorporate the 2020 National Health Goals for pregnant
women with special needs? (Select all that apply.)
A) Importance of an adequate fluid intake
B) Effects of alcohol on the developing fetus
C) Use of complementary therapy for delivery
D) Abstinence from illicit drugs while pregnant
E) Impact of cigarette smoking on the developing fetus
Ans: B, D, E
Feedback:
The 2020 National Health Goals for pregnant women with special needs focus on
teaching unintentional injury prevention, the dangers and complications of substance
dependency, and both the psychological and physical concerns of teenage pregnancy.
The nurse should include the topics that focus on alcohol, illicit drugs, and cigarette
smoking. An adequate fluid intake is not a topic specific to a pregnant woman with
special needs. The use of complementary therapy for delivery might not be appropriate
for a pregnant adolescent because of cephalopelvic disproportion.
2. A pregnant adolescent asks if the father of the baby can come into the room during the
examination. Based on both the pregnant adolescent's and the father's needs, which is
the best response for the nurse to make?
A) “If your parents approve.”
B) “If you want him to come in.”
C) “Adolescent fathers have no legal right in regard to a child.”
D) “Not participating will help him be more responsible in the future.”
Ans: B
Feedback:
If the baby's father attends prenatal care, help him to feel welcome. Because he is not
married, he does not have a legal right to participate in decisions concerning the
pregnancy, abortion, or adoption, but he may not be devoid of feelings for the girl or the
baby. If a complication occurs, he may feel genuine grief things are not going well.
Allowing him to offer support in the current pregnancy can help him learn more about
himself as well as better define his role. In addition, be sure he receives compassionate
education on preventing further pregnancies until he is more mature. The nurse does not
need the parent's approval for the father of the baby to be present during the
examination.
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3. The nurse is identifying nursing diagnoses appropriate for a pregnant patient who is
substance dependent. Which diagnosis should the nurse identify as applicable to this
patient's needs?
A) Impaired home maintenance related to a sensory challenge
B) Risk for disruption of social interaction related to unclear speech
C) Risk for injury to self and fetus related to chronic substance dependency
D) Readiness for enhanced family coping, related to commitment to have a child in
the face of a disabling condition
Ans: C
Feedback:
Illicit drugs can pass through the placenta and affect the developing fetus. The patient is
also being harmed by the drugs. The most appropriate diagnosis for the patient would be
risk for injury to self and fetus related to chronic substance dependency. Impaired home
maintenance, risk for disruption of social interaction, and readiness for enhanced family
coping would be appropriate for the pregnant patient who is physically or cognitively
challenged.
4. When planning care for a pregnant adolescent, what nursing action supports the
developmental task of this age group?
A) Allow to weigh self at clinic visits.
B) Insist that no further sexual relations occur during pregnancy.
C) Suggest that schooling be delayed until the pregnancy is over.
D) Encourage deciding on the total weight gain for her pregnancy.
Ans: A
Feedback:
Helping adolescents to make their own health care decisions at health care visits helps to
foster a sense of independence. During a visit, the adolescent can weigh herself to feel
independent. Insisting that no further sexual relations occur and delaying school do not
foster a sense of independence. Permitting the pregnant adolescent to determine the total
weight gain for the pregnancy would not be safe considering the patient is still
developing physically.
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5. The nurse is reviewing nutritional needs with a pregnant adolescent. Which topic should
the nurse include in the teaching plan for this patient?
A) Ways to remember to take an iron supplement daily
B) Ways to obtain good pregnancy nutrition in restaurants
C) Nutritional advantages of fresh foods over frozen foods
D) Ways the pregnant adolescent can learn to cook her own food
Ans: A
Feedback:
Adolescents traditionally do not take medicine conscientiously, so they may need
frequent reminders to take their vitamin or iron supplement. Stress these are intended to
complement nutrition during pregnancy. For a reminder system, girls may need to post a
medication reminder chart at home or in her school locker or set a reminder on her
phone in order to increase adherence. Obtaining good pregnancy nutrition in restaurants,
advantages of fresh foods, and learning to cook may or may not be appropriate to meet
the nutritional needs of the pregnant adolescent.
6. A pregnant adolescent is upset because she is not permitted to deliver the baby at an
alternative birthing center. Why is the use of an alternative birthing center
contraindicated for this patient?
A) High risk for pelvic disproportion
B) The patient's parents disapproved of the center
C) Alternative birth centers admit only married women
D) Alternative birthing centers only admit patients over the age of 21 years
Ans: A
Feedback:
Pregnant adolescents are prone to cephalopelvic disproportion because of the patient's
incomplete pelvic growth. Using a birthing center could be dangerous for the patient and
the fetus. The use of a birthing center is not contraindicated because the patient's parents
disapprove of the center. There are no restrictions such as marital status or age on the
use of a birthing center.
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7. A pregnant adolescent has many questions and concerns about the pregnancy and
birthing process. What should the nurse recommend to this patient?
A) Talk to her mother.
B) Attend childbirth classes.
C) Obtain books from the library.
D) Ask the health care provider the questions.
Ans: B
Feedback:
Peer companionship is a strong need for most adolescents. When girls become pregnant,
because they are suddenly so different, they may find themselves cut off from fellow
classmates. This is the prime opportunity to join a class of other adolescents in
preparation for childbirth. The pregnant adolescent may or may not have a good
relationship with her mother. The pregnant adolescent needs more than reading books
about the pregnancy and childbirth. The health care provider may or may not be able to
answer all of the pregnant adolescent's questions.
8. An adolescent patient delivers an 8-lb baby after being in labor for 12 hours. During the
postpartal period, which assessment is a priority for the nurse to complete?
A) Endometritis
B) Thrombophlebitis
C) Amniotic embolus
D) Postpartum hemorrhage
Ans: D
Feedback:
Adolescents are more prone to postpartum hemorrhage than the average woman because
if the patient's uterus is not yet fully developed, it becomes overdistended by pregnancy.
An overdistended uterus will not contract as readily as a normally distended uterus in
the postpartum period. This can lead to hemorrhage. Endometriosis, thrombophlebitis,
and amniotic embolus are not expected postpartal complications for the adolescent
patient.
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9. A postpartum patient who is severely hearing impaired is silently holding the newborn.
What should the nurse suggest the patient do when caring for the baby?
A) Avoid speaking to her newborn.
B) Put on the television to make noise.
C) Use a radio as a source of sound for the baby.
D) Speak and sing to the child as care is being given.
Ans: D
Feedback:
If the baby hears, urge the patient to talk to the infant as care is given so the baby is
introduced to sounds and words. Some patients whose speech is severely affected by a
hearing disorder are reluctant to speak to strangers. Assure the patient that the infant
welcomes the sound of her voice and will quiet readily to the sound. Being spoken to
and sung to during the first year is important for overall development. The patient
should not avoid speaking to the newborn. The sound of the mother's voice is preferred
over the sound of television or radio.
10. The nurse is caring for a 41-year-old patient who is pregnant with her first child. What
can the nurse suggest to reduce the development of varicosities from the pregnancy?
(Select all that apply.)
A) Jog in place.
B) Take walk breaks.
C) Rest in the Sims position.
D) Increase the intake of vitamin D.
E) Rest with the legs on a foot stool.
Ans: B, C, E
Feedback:
Interventions to reduce the development of varicosities while pregnant include taking
walk breaks, resting in the Sims position, and resting with the legs elevated on a foot
stool. Jogging in place will not reduce the onset of varicosities and might harm the
patient and fetus. The patient should increase the intake of vitamin C, and not vitamin
D, because vitamin C strengthens vein walls.
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11. A pregnant patient with a thoracic-level spinal cord injury from a skiing accident is
confined to a wheelchair for ambulation. What should the nurse encourage the patient to
do during pregnancy?
A) Raise the buttocks off the wheelchair seat every hour.
B) Hold the breath hourly to cause descent of the diaphragm.
C) Tense abdominal muscles hourly to maintain abdominal tone.
D) Do pelvic rocking movements every hour to maintain vertebral mobility.
Ans: A
Feedback:
Patients who use wheelchairs are taught to press the hands against the armrests and lift
the buttocks up off the wheelchair seat for 5 seconds every hour to prevent the
formation of pressure ulcers on the buttocks and posterior thighs. Encourage a pregnant
woman to continue to perform this maneuver during pregnancy because the increased
weight of a fetus increases the risk for pressure ulcer formation from additional
compression. The nurse should not encourage the pregnant patient to hold the breath,
tense abdominal muscles, or do pelvic rocking movements.
12. A postpartum patient with a high spinal cord injury has an indwelling urinary catheter
placed for a cesarean birth. The patient's face is red and is complaining of a headache. A
current blood pressure measurement is 160/120 mmHg. What should the nurse do first?
A) Immediately cut and remove the indwelling catheter.
B) Sit the patient up abruptly and massage the lower back.
C) Raise the head of the bed and assess the catheter for blockage.
D) Lower the head of the bed and coach to breathe slowly in and out.
Ans: C
Feedback:
In a patient with a high spinal cord injury, the nurse needs to observe for autonomic
dysreflexia during pregnancy, labor, and the immediate postpartum period. This is an
exaggerated autonomic response to stimuli. Any irritating condition, such as a distended
bladder, may initiate the response. Symptoms include severe hypertension, throbbing
headache, and flushing of the skin. Immediate action is needed and includes elevating
the patient's head to reduce cerebral pressure and locate the irritating stimulus, which is
usually a distended bladder. If bladder distention is the cause and a catheter is in place,
check to see why it is not draining and then encourage it to drain by unkinking or
flushing to allow urine to flow freely again. As soon as the source of irritation is
removed, symptoms typically fade quickly. The indwelling catheter does not need to be
removed. Massaging the lower back will not help the symptoms. Lowering the head of
the bed could cause the patient to have worsening symptoms.
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13. The nurse instructs a pregnant patient on ways to reduce unintentional injuries while
pregnant. Which patient statement indicates that teaching has been effective?
A) “I should clean a puncture wound with cold water.”
B) “I should wear a seat belt when in a motor vehicle at all times.”
C) “I should lie down and rest if someone kicks or punches my abdomen.”
D) “I should flush an animal bite with warm water and then wash with soap.”
Ans: B
Feedback:
Pregnancy counseling should include education about ways to avoid unintentional
injuries such as using automobile seat belts. Puncture wounds need to be evaluated for
depth. The patient might need a tetanus injection after this type of injury. If someone
punches or kicks the pregnant patient's abdomen, the patient needs to be evaluated for
damage to the uterus, bladder, or placenta. If the pregnant patient receives an animal
bite, it needs to be evaluated and determined if the animal was rabid. If so, the patient
needs rabies inoculations, which are safe to administer during pregnancy.
14. A pregnant patient slipped and fell on an icy sidewalk a few weeks ago. During labor,
the patient is experiencing extreme pain at the region of the symphysis pubis. What
should be done to help this patient?
A) Elevate the legs.
B) Position on the side.
C) Apply heat to the region.
D) Provide additional pain medication.
Ans: D
Feedback:
The laxness of body cartilage may cause separation of the symphysis pubis if a pregnant
patient falls with the legs outspread. A suture separation this way is very painful,
especially on walking or turning. If separation of the symphysis pubis is still present at
the time of birth, this can make labor very painful, especially during the pelvic division
of labor as the fetus is pushed through the pelvic ring. The patient may need additional
analgesia at this time. Elevating the legs, positioning on the side, or applying heat to the
region will not help with the pain from the injury.
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15. The nurse is concerned that a pregnant patient is using cocaine. What should the nurse
suggest to the health care provider to confirm this suspicion?
A) Urinalysis
B) Electrocardiogram
C) Complete blood count
D) Stool test for occult blood
Ans: A
Feedback:
Cocaine use can be detected by urinalysis because the metabolites of cocaine can be
detected in urine up to 1 week after use. Electrocardiogram, complete blood count, and
stool test for occult blood will not confirm the use of cocaine in the pregnant patient.
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Chapter 23 Nursing Care of a Family Experiencing a Complication of Labor or Birth
1. A pregnant patient in labor is having contractions 2 minutes apart but rarely over 50
mmHg in strength; the resting tone is high, 20 to 25 mmHg. The patient asks what can
be done to make contractions more effective. What should the nurse respond to the
patient?
A) Rest because contractions are hypertonic.
B) Receive oxytocin to strengthen contractions.
C) Hypotonic contractions of this kind will strengthen by themselves.
D) Walking around will make the contractions more regular.
Ans: A
Feedback:
A danger of hypertonic contractions is that the lack of relaxation between contractions
may not allow optimal uterine artery filling; this can lead to fetal anoxia early in the
latent phase of labor. The best intervention is to encourage the patient to rest between
contractions. Oxytocin will not help strengthen hypertonic contractions. Walking will
not help make the contractions more regular. These are hypertonic and not hypotonic
contractions.
2. A patient in labor has been prescribed an intravenous infusion of 5% dextrose/water.
Following insertion of the intravenous line, what should the nurse instruct the patient to
do?
A) Try to forget the fluid line is in place.
B) Lie on the back to allow optimal flow.
C) Not to get out of bed once the needle is in place.
D) Lie perfectly still so as not to dislodge the needle.
Ans: A
Feedback:
Many patients react negatively to the idea of IV fluid therapy during labor to restore
body fluid. Assure the patient that being out of bed and walking, turning freely,
squatting, sitting, or using whatever position preferred during labor will not disrupt the
IV line or the infusion. The nurse should not tell the patient to lie on the back or to lie
perfectly still. The patient should also be encouraged to get out of bed if that is
permitted and desired by the patient in labor.
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3. A patient in labor has reached 8 cm dilation, but the fetal heart rate suddenly slows.
Perineal inspection reveals a prolapsed fetal cord. What should the nurse do first?
A) Turn the patient onto the left side.
B) Replace the cord with gentle pressure.
C) Place the patient in a knee–chest position.
D) Cover the exposed cord with a dry, sterile wrap.
Ans: C
Feedback:
Prolapsed cord is always an emergency situation because the pressure of the fetal head
against the cord at the pelvic brim leads to cord compression and decreased oxygenation
to the fetus. Pressure on the cord must be relieved, which is done by placing the patient
in a knee–chest or Trendelenburg position to cause the fetal head to fall back from the
cord. Turning the patient onto the left side will not relieve pressure on the fetal cord.
Any amount of prolapsed cord should not be reinserted into the patient. Exposed cord
should be covered with sterile saline compresses to prevent drying.
4. A pregnant patient is prescribed to have labor induced with oxytocin. How should the
nurse prepare to administer this medication?
A) In a 20-cc bolus of saline
B) In two divided intramuscular sites
C) Diluted as a “piggyback” infusion
D) Diluted in the main intravenous fluid
Ans: C
Feedback:
When administering oxytocin, the infusion should be “piggybacked” to a maintenance
IV solution and add the piggyback to the main infusion at the port closest to the patient.
If the oxytocin needs to be discontinued quickly during the induction, little solution
remains in the tubing to still infuse, and the main IV line can still be maintained.
Oxytocin is not administered as an intravenous bolus, as intramuscular injections, nor is
it diluted in the main intravenous fluid.
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5. After an hour of oxytocin therapy, a patient in labor experiences headache and vomiting.
What should the nurse do?
A) Assess the vagina for full dilation.
B) Notify the physician and stop the infusion.
C) Instruct the patient to breathe in and out rapidly.
D) Administer oral orange juice for added potassium.
Ans: B
Feedback:
A side effect of oxytocin is that it can result in decreased urine flow, possibly leading to
water intoxication. This is first manifested by headache and vomiting. If these danger
signs are observed in the patient during induction of labor, report them immediately and
halt the infusion. Assessing the vagina for dilation, increasing respirations, and
administering orange juice for potassium will not help with water intoxication.
6. A pregnant patient receiving intravenous oxytocin for 1 hour has contractions lasting 80
seconds. What should the nurse do first for this patient?
A) Discontinue the oxytocin infusion.
B) Slow the infusion to below 10 gtt/minute.
C) Increase the flow rate of the main line infusion.
D) Continue to monitor contraction duration every 2 hours.
Ans: A
Feedback:
Contractions should last no longer than 70 seconds. If contractions become longer in
duration, stop the IV infusion and seek help immediately. The infusion needs to be
discontinued and not slowed. Increasing the flow rate could cause fetal distress. The
patient needs to be assessed more frequently than every 2 hours.
7. The nurse is assessing a patient in labor. On which complication of labor as identified
within the 2020 National Health Goals will the nurse focus?
A) Uterine rupture
B) Prolapsed fetal cord
C) Hypotonic contractions
D) Hypertonic contractions
Ans: A
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for complications of
labor by being alert to the preliminary symptoms of uterine rupture, which accounts for
a substantial number of maternal deaths during labor. Hypotonic and hypertonic
contractions and prolapsed fetal cord are not identified as specific complications of
labor within the 2020 National Health Goals.
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8. An infant was born after a face presentation. When selecting a nursing diagnosis for the
newborn, which body system does the nurse identify as a priority?
A) Respiratory
B) Genitourinary
C) Cardiovascular
D) Gastrointestinal
Ans: A
Feedback:
Babies born after a face presentation have a great deal of facial edema and may be
purple from bruising. The infant must be observed closely for a patent airway, which is
the priority. A face presentation does not affect the cardiovascular or genitourinary
systems. If lip edema is severe, the newborn might need gavage feedings until the
edema subsides and sucking can occur.
9. The fetus of a pregnant patient is in a breech presentation. Where will the nurse
auscultate fetal heart sounds?
A) Low in the abdomen
B) Left lateral abdomen
C) High in the abdomen
D) Right lateral abdomen
Ans: C
Feedback:
With a breech presentation, fetal heart sounds usually are heard high in the abdomen. In
a breech presentation, fetal heart sounds will not be heard low in the abdomen or over
the left or right lateral abdominal regions.
10. A patient is experiencing dysfunctional labor, which is prolonging the descent of the
fetus. Which teaching should the nurse prepare to provide to this patient?
A) Oxytocin therapy
B) Fluid replacement
C) Pain management
D) Increasing activity
Ans: A
Feedback:
With a prolonged descent, intravenous oxytocin may be used to induce the uterus to
contract effectively. Fluid replacement, pain management, and activity will not cause
the fetus to descend quicker.
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11. After delivery, a patient is diagnosed with placenta succenturiata. For what procedure
should the nurse prepare this patient?
A) Lavage of the uterus
B) Repair of an episiotomy
C) Manual removal of accessory lobes
D) Emergency resuscitation of the newborn
Ans: C
Feedback:
A placenta succenturiata is a placenta that has one or more accessory lobes connected to
the main placenta by blood vessels. This disorder needs to be recognized because the
small lobes may be retained in the uterus after birth, leading to severe maternal
hemorrhage. Once the remaining lobes are recognized and removed from the uterus
manually, the uterus will contract with no adverse maternal effects. Uterine lavage is not
a treatment for this disorder. This disorder is not specifically associated with an
episiotomy. No fetal abnormality is associated with this disorder.
12. The nurse is caring for a patient in labor whose fetus is in an occiput posterior position.
Which intervention should the nurse use to reduce this patient's discomfort?
A) Massage the lower back.
B) Place in a prone position.
C) Apply ice packs to the lower back.
D) Place in the Trendelenburg position.
Ans: A
Feedback:
Because the fetal head rotates against the sacrum in the occiput posterior position, the
patient may experience pressure and pain in the lower back because of sacral nerve
compression. Applying counter pressure on the sacrum by a back rub may be helpful in
relieving a portion of the pain. The patient does not need to be placed in the prone or
Trendelenburg positions. Ice packs are not indicated to reduce this pain.
13. While the placenta is being delivered after labor, a patient experiences an amniotic fluid
embolism. What should the nurse do first to help this patient?
A) Administer oxygen by mask.
B) Increase intravenous fluid infusion rate.
C) Put firm pressure on the fundus of the uterus.
D) Tell the patient to take short, shallow breaths.
Ans: A
Feedback:
The clinical picture of an amniotic fluid embolism is dramatic. The patient suddenly
experiences sharp chest pain and is unable to breathe as pulmonary artery constriction
occurs. The immediate management is oxygen administration by face mask or cannula.
Intravenous fluids; pressure on the fundus; or taking short, shallow breaths is not going
to help the manifestations of an amniotic fluid embolism.
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14. A patient in labor has a spinal cord injury and is unable to effectively push with
contractions. Forceps will be used. What should the nurse do to prepare the patient for
this type of delivery? (Select all that apply.)
A) Provide oxygen 2 L via face mask.
B) Validate that the cervix is fully dilated.
C) Determine that the patient's bladder is empty.
D) Begin an intravenous infusion of replacement fluid
E) Ensure that the patient's membranes have ruptured.
Ans: B, C, E
Feedback:
Prior to using forceps for a delivery, the cervix must be fully dilated, the patient's
bladder must be empty, and the patient's membranes must have ruptured. The patient
does not need oxygen for a forceps delivery. The patient does not need an intravenous
infusion prior to a forceps delivery.
15. The nurse is evaluating care provided to a patient giving birth to her first child. Which
outcome regarding labor indicates that care has been effective?
A) Client achieved 4 cm of dilation after 7 hours of labor.
B) Client achieved full dilatation after 8 hours of labor.
C) Client delivered infant within 2 hours after full dilatation with epidural.
D) Client delivered infant within 30 minutes after full dilatation without epidural.
Ans: A
Feedback:
For a nulliparous patient, achievement of 4 cm of dilation after 7 hours of labor is
expected and indicates that care has been effective. Full dilatation after 8 hours is
appropriate for a multiparous patient. Delivering the infant within 2 hours after full
dilatation with an epidural is appropriate for a multiparous patient. Delivering the infant
within 30 minutes after full dilatation without an epidural is appropriate for a
multiparous patient without an epidural.
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16. A pregnant patient tells the nurse that she hopes the baby is not in the breech position
because she has heard that this causes difficult labor. What should the nurse include
when explaining the reasons for this presentation to the patient? (Select all that apply.)
A) Multiple fetuses
B) Maternal diabetes
C) Fetal birth defects
D) Lax abdominal muscles
E) Fetal age less than 40 weeks
Ans: A, C, D, E
Feedback:
Reasons for the breech presentation include multiple fetuses, lax abdominal muscles,
fetal birth defects such as hydrocephalus, and fetal age less than 40 weeks. Maternal
diabetes is not identified as cause for a fetal breech presentation.
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Chapter 24 Nursing Care of a Family During a Surgical Intervention for Birth
1. The nurse is caring for a patient recovering from a cesarean birth. Which assessment
should the nurse make a priority for this patient?
A) Breast filling
B) Plan to breastfeed
C) Abdominal texture
D) Perineum for edema
Ans: C
Feedback:
After a cesarean birth, the nurse should assess the abdomen for softness. A hard,
“guarded” abdomen is one of the first signs of peritonitis, a complication that may occur
with any abdominal surgical procedure. Although important, breast filling does not lead
to a life-threatening complication. Plans to breastfeed could have been determined prior
to the cesarean birth. Because the baby was delivered through the abdomen, the
perineum should not be edematous.
2. A patient who had a previous cesarean birth asks the nurse if all future births must occur
the same way. Which response should the nurse make to support the 2020 National
Health Goals regarding cesarean births?
A) “All future births must be done through cesarean.”
B) “Not if you fulfill the criteria for vaginal birth after cesarean.”
C) “Your health care provider will let you know what kind of birth you can have.”
D) “Most women prefer cesarean births because they are quicker and cause less
pain.”
Ans: B
Feedback:
To fulfill the 2020 National Health Goals regarding cesarean births and answer the
patient's question, the nurse should respond that patients who fulfill the criteria for
vaginal birth after cesarean should attempt a vaginal birth with subsequent children. All
future births do not need to be done through cesarean. The patient has a voice with
deciding the type of birth that she would prefer with each pregnancy. Most women do
not prefer cesarean births. This type of birth might not take as long; however, it is a
painful surgical procedure.
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3. A patient whose fetus is presenting breech is scheduled to have a cesarean birth. What
should the nurse anticipate this patient will need to ensure maximum postoperative care?
A) Bed rest for the first 4 days
B) Insertion of a nasogastric tube
C) Maintenance of an indwelling catheter
D) Separation from the infant for 72 hours
Ans: C
Feedback:
To reduce bladder size and keep the bladder away from the surgical field, an indwelling
urinary catheter may be prescribed before transport for surgery or after arrival in the
surgical suite. Because the bladder was handled and displaced during surgery, its tone or
ability to sense filling may be inadequate to initiate voiding for the first postoperative
day. For this reason, the indwelling catheter placed before surgery is usually left in place
for 4 to 24 hours to ensure good urine drainage. The patient will not be on bed rest for 4
days after a cesarean birth. A nasogastric tube is not indicated for a cesarean birth. The
infant will not be separated from the mother for 72 hours after a cesarean birth.
4. A woman is scheduled to have epidural anesthesia for a cesarean birth. What should the
nurse anticipate to include in the preoperative plan of care while the patient waits for the
anesthetic?
A) Encouraging her to ambulate
B) Administering an oral antacid
C) Administering morphine sulfate
D) Keeping in a side-lying position
Ans: D
Feedback:
The side-lying position helps prevent supine hypotension syndrome, and epidural
anesthesia is usually administered with the patient lying on the side. Ambulation prior to
anesthesia may or may not be indicated for the patient. Oral antacids and morphine
sulfate are not a part of preparation for epidural anesthesia.
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5. A patient scheduled for a cesarean birth asks if there are any difficulties with
breastfeeding after this type of delivery. What should the nurse include when
responding to this patient?
A) Breastfeeding is not recommended after a cesarean birth.
B) It is hard to find a comfortable position to hold a newborn to breastfeed.
C) A comfortable position can be found to support breastfeeding the infant.
D) The patient will have too much analgesia postoperatively to make breastfeeding
safe.
Ans: C
Feedback:
The nurse can help the patient with breastfeeding by placing a pillow over the lap while
the infant nurses. This position can deflect the weight of the infant from the suture line
and lessen pain. The use of the football hold for breastfeeding is another way to keep the
infant's weight off the incision. Breastfeeding is recommended after a cesarean birth. It
is not difficult to find a comfortable position to hold a newborn to breastfeed. The
patient will not have too much analgesia postoperatively for safe breastfeeding.
6. A patient, preparing for patient-controlled analgesia for pain relief after a cesarean birth,
asks if this is an effective way to control pain. What should the nurse respond to the
patient?
A) “It is effective, but the amount of analgesic used will preclude breastfeeding.”
B) “Every woman reacts differently to pain, so it would be impossible to predict.”
C) “Not only is it effective but it also will reduce the amount of narcotic needed.”
D) “Most women do not feel well enough after surgery to want control of their own
pain relief.”
Ans: C
Feedback:
With patient-controlled analgesia, a constant level of pain relief can be maintained, and
pain and fear of injections are eliminated. This approach works well with postcesarean
patients because the narcotic is injected in such small amounts; patients tend to use less
analgesia with this approach than they would receive with intramuscular injections.
Breastfeeding is not contraindicated with patient-controlled analgesia. Patient-controlled
analgesia has proven to be an effective method to control pain. Most patients like
patient-controlled analgesia because they are able to control their own pain relief.
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7. A patient who has been in labor for 20 hours is being prepared for an emergent cesarean
birth. Which action will help ensure the patient's fluid status during the procedure?
A) Provide with a clear liquid tray.
B) Encourage intake with ice chips.
C) Initial intravenous fluid therapy.
D) Administer an antiemetic as prescribed.
Ans: C
Feedback:
A patient who enters surgery with a lower than usual blood volume will experience the
effect of surgical blood loss more than a patient who has a normal blood volume. A
patient who has had a long labor before a cesarean birth is scheduled may fall into this
category, because the patient may have had little to eat or drink for almost 24 hours.
Intravenous fluid replacement needs to be initiated preoperatively and continued
postoperatively to prevent a serious fluid or electrolyte imbalance. Since surgery is
imminent, the patient should be kept at “nothing by mouth” status, which means no ice
chips or clear liquids. An antiemetic is not indicated for the patient at this time.
8. Following a cesarean birth, a patient is prescribed to receive intravenous fluids. At
which time should the nurse anticipate that this patient will be able to resume an oral
intake?
A) 24 hours postprocedure
B) 48 hours postprocedure
C) When bladder tone returns
D) When bowel sounds return
Ans: D
Feedback:
Patients are kept at “nothing by mouth” status for a period of time after surgery until
intestinal peristalsis has returned. To establish this is returning, the patient's abdomen
should be assessed at least once every 8 hours for bowel sounds because this
demonstrates air and fluid are moving through the intestines. As soon as bowel sounds
return, IV fluid therapy is usually discontinued and the patient can slowly begin oral
intake with fluids. Oral intake may or may not be permitted 24 to 48 hours after the
procedure. Oral intake is not contingent on bladder tone.
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9. The nurse encourages a patient recovering from a cesarean birth to begin early
ambulation. For which outcome would this action be indicated?
A) Patient will tolerate clear liquids.
B) Patient will have no evidence of wound infection.
C) Patient will successfully begin breastfeeding the infant.
D) Patient will not develop manifestations of thrombophlebitis.
Ans: D
Feedback:
Early ambulation is an intervention to avoid lower extremity circulatory problems such
as thrombophlebitis. Early ambulation is not an intervention to improve tolerance for
clear liquids, prevent wound infection, or have success with breastfeeding.
10. The fetus of a patient who is 30 weeks pregnant is failing to thrive in utero. The health
care provider wants to deliver the fetus through cesarean birth today. The patient asks
why this approach is preferred over a vaginal delivery. What should the nurse respond
to the patient?
A) “You will have reduced pain afterward.”
B) “There's not an advantage; it's just more convenient.”
C) “Cesarean birth allows the placenta to deliver easier.”
D) “Cesarean birth will reduce pressure on the immature head.”
Ans: D
Feedback:
A cesarean delivery may be advantageous for a preterm birth to avoid pressure on the
fetal head. A cesarean birth does not reduce the amount of postpartum pain. The health
care provider does not want to use a cesarean birth because it is more convenient. A
cesarean birth does not necessarily allow the placenta to deliver easier.
11. A patient having a cesarean birth will have a low segment incision. What should the
nurse explain to the patient as an advantage for this type of incision?
A) The uterine incision will be vertical.
B) Vaginal deliveries can occur with future births.
C) Because the cervix is cut, the operation proceeds rapidly.
D) Because the fundus of the uterus is cut, the infant can be resuscitated rapidly.
Ans: B
Feedback:
Because a low segment incision is through the nonactive portion of the uterus, it is less
likely to rupture in subsequent labors, making it possible for a woman to have a vaginal
birth after cesarean with a future pregnancy. This type of incision is not vertical. The
cervix is not cut with this type of incision. This type of incision has no impact on the
ability to resuscitate the infant if necessary.
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12. After learning about the need for a cesarean birth, the pregnant patient begins to cry and
hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the
patient needs at this time?
A) Fear related to impending surgery
B) Risk for infection related to a surgical incision
C) Powerlessness related to medical need for cesarean birth
D) Risk for impaired parent/infant attachment related to unplanned method of birth
Ans: A
Feedback:
The patient's emotional response after learning about a cesarean birth is most likely fear.
The nurse should use the diagnosis of “fear related to impending surgery” to guide
interventions at this time. The patient's emotional response is not likely because of a risk
of infection, powerlessness, or a risk for impaired parent/infant attachment.
13. The nurse assists while a pregnant patient has an amniotomy. Which action should the
nurse take immediately at the conclusion of the procedure?
A) Assess fetal heart rate.
B) Adjust intravenous fluid infusion rate.
C) Assist the patient to wash the perineum.
D) Provide clean gown and linens for the patient.
Ans: A
Feedback:
Amniotomy is the artificial rupturing of membranes during labor. A disadvantage of
amniotomy is it puts a fetus momentarily at risk for cord prolapse if a loop of cord
escapes into the vagina with the fluid. Always measure the fetal heart rate immediately
after the rupture of membranes to determine this did not occur. The nurse can assist the
patient with washing and applying a clean gown and linens after the fetal heart rate is
assessed. The patient may or may not have an intravenous infusion at this time.
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14. The nurse is concerned that a pregnant patient will have a complication from a
medication after a cesarean birth. For which prescribed medications are complications
most likely to occur? (Select all that apply.)
A) Insulin
B) Anticoagulant
C) Antihypertensive
D) Antianxiety agent
E) Beta2-adrenergic blocker
Ans: A, B, C, D
Feedback:
Some medications can cause complications with cesarean births. Insulin may lead to
hypoglycemia during labor or hyperglycemia if a dextrose solution is provided.
Anticoagulants may cause hemorrhage due to lack of hemostasis during surgery.
Antihypertensives may result in hypotension after anesthesia. Antianxiety agents may
cause hypotension after anesthesia. There is no evidence to suggest that beta2-adrenergic
blockers will cause a complication after a cesarean birth.
15. The nurse is preparing a teaching plan for a patient recovering from a cesarean birth.
What should the nurse instruct the patient to help improve stamina and energy after the
procedure?
A) Drink at least six glasses of fluid each day.
B) Limit social events to family and close friends.
C) Rest twice a day for at least one-half hour each time.
D) Slowly increase the amount of weight carried each day.
E) Structure the day so that house cleaning and shopping is completed.
Ans: A, C
Feedback:
To help a patient recovering from a cesarean birth regain stamina and energy, the nurse
should instruct the patient to drink at least six glasses of fluid each day and rest twice a
day for at least one-half hour each time. There is no limit to social events; however, the
patient should not be expected to be a social hostess during this time. The amount of
weight lifted should be restricted to the weight of the new baby and not increased each
day. The patient should accept help from family and friends for house cleaning and
shopping. The patient should not structure the day so that these activities are completed.
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Chapter 25 Nursing Care of a Family Experiencing a Postpartum Complication
1. A patient who gave birth 5 hours ago has completely saturated a perineal pad within 15
minutes. Which action by the nurse should be implemented first?
A) Assess vital signs.
B) Assess the fundus.
C) Notify the health care provider.
D) Begin an IV infusion of Ringer's lactate solution.
Ans: B
Feedback:
The best safeguard against uterine atony is to palpate the fundus at frequent intervals to
be assured that the uterus is remaining contracted. If bleeding persists, then vital signs
assessment and notification to the health care provider may be indicated. An intravenous
infusion might be prescribed if bleeding continues.
2. The nurse is reviewing orders written for a postpartum patient with a fourth-degree
perineal laceration. Which order should the nurse question before implementing?
A) Providing a sitz bath
B) Administering an enema
C) Urging to drink all the milk provided during meals
D) Administering acetaminophen and codeine for pain
Ans: B
Feedback:
A fourth-degree perineal laceration involves the entire perineum, rectal sphincter, and
some of the mucous membrane of the rectum. Any patient who has a fourth-degree
laceration should not have an enema prescribed because the hard tips of equipment
could open sutures near to or including those of the rectal sphincter.
3. The nurse is concerned that a postpartum patient with a cervical laceration is developing
hypovolemic shock. What did the nurse assess in this patient?
A) Weak and rapid pulse
B) Warm and flushed skin
C) Elevated blood pressure
D) Decreased respiratory rate
Ans: A
Feedback:
If the loss of blood is extremely copious, a woman will quickly begin to exhibit
symptoms of hypovolemic shock such as a weak and rapid pulse. The skin will be pale
and clammy, and the blood pressure will fall. Respiratory rate will be increased and
shallow.
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4. The nurse is planning interventions to prevent the onset of urinary retention in a
postpartum patient. Why are these interventions needed?
A) Frequent partial voiding never relieves the bladder pressure.
B) Catheterization at the time of delivery reduces bladder tonicity.
C) Mild dehydration causes a concentrated urine volume in the bladder.
D) Decreased bladder sensation results from edema because of pressure of birth.
Ans: D
Feedback:
Urinary retention occurs when there is inadequate bladder emptying. After childbirth,
bladder sensation for voiding is decreased because of bladder edema caused by the
pressure of birth. Frequent partial voiding can lead to bladder overdistention.
Catheterization at the time of delivery will not reduce bladder tone. Dehydration will not
cause urinary retention but an overall reduction in urine volume.
5. After delivery, a patient is diagnosed with postpartal gestational hypertension. What
care will the nurse provide to this patient? (Select all that apply.)
A) Maintain on bed rest.
B) Monitor urine output.
C) Instruct on the purpose of a fluid restriction
D) Administer magnesium sulfate as prescribed.
E) Administer antihypertensive medication as prescribed.
Ans: A, B, D, E
Feedback:
Treatment for postpartal gestational hypertension includes bed rest, monitoring of urine
output, and administration of magnesium sulfate or an antihypertensive agent. Fluid
restriction is not indicated for postpartal gestational hypertension.
6. A postpartum patient is prescribed methylergonovine (Methergine) 0.2 mg for uterine
subinvolution. Which action should the nurse take before administering the medication
to the patient?
A) Assess ambulation.
B) Measure urine output.
C) Measure blood pressure.
D) Evaluate current hematocrit level.
Ans: C
Feedback:
Methylergonovine (Methergine) can increase blood pressure and must be used with
caution in patients with hypertension. The nurse should assess the blood pressure prior
to administrating and about 15 minutes afterward to detect this side effect.
Methylergonovine (Methergine) does not affect ambulation, urine output, or hematocrit
level.
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7. A patient is receiving treatment for a postpartum complication. Which action should the
nurse perform to support the 2020 National Health Goals during the postpartum period?
A) Encourage to continue breastfeeding.
B) Suggest breastfeeding be discontinued.
C) Instruct on supplementing feedings with formula.
D) Explain how breastfeeding will weaken the patient's condition.
Ans: A
Feedback:
The postpartal period is a time when patients are susceptible to complications and may
choose not to breastfeed. Nurses can help the nation achieve the 2020 National Health
Goals by encouraging women to breastfeed even in the face of a postpartal
complication. Suggesting that breastfeeding be discontinued or using supplemental
feedings will not support the national goals. Breastfeeding is not known to weaken the
patient's condition while being treated for a complication.
8. The nurse is instructing a postpartum patient on observations to report to the health care
provider which signifies retained placental fragments. Which patient statement indicates
that teaching has been effective?
A) “If the drainage changes from clear to bright red, I am to call the doctor.”
B) “I will have large amount of vaginal drainage for at least several months.”
C) “An elevated temperature is normal during the first few weeks after delivery.”
D) “My drainage will fluctuate between bright red and dark red for several weeks.”
Ans: A
Feedback:
Because the hemorrhage from retained fragments may be delayed until after the patient
is home, instruct to observe the color of lochia and to report any tendency for the
discharge to change from lochia serosa or alba back to rubra. The patient will not have
large amounts of drainage for several months. An elevated temperature indicates an
infection. The drainage should not fluctuate between bright and dark red and could
indicate retained placental fragments.
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9. A postpartum patient has a swollen area of purplish discoloration in the perineal area
that is 5 cm in diameter. Which nursing diagnosis should the nurse use to plan care for
this patient?
A) Acute pain
B) Risk for injury
C) Risk for infection
D) Ineffective peripheral tissue perfusion
Ans: A
Feedback:
The nursing diagnosis of acute pain would be appropriate because of a collection of
blood in traumatized tissue secondary to birth trauma. Risk for injury would be
appropriate if the patient was demonstrating signs of postpartum depression or
psychosis. Risk for infection would be appropriate if the patient had an elevated
temperature. Ineffective peripheral tissue perfusion would be appropriate if the patient
was demonstrating signs of thrombophlebitis.
10. A postpartum patient is receiving antibiotics for endometritis. What should the nurse
instruct the patient to observe in the infant with breastfeeding?
A) Jaundice
B) Irritability
C) Decreased sleep levels
D) White plaques in the mouth
Ans: D
Feedback:
The patient who is breastfeeding should not be prescribed antibiotics that are
incompatible with breastfeeding. The patient should be instructed to observe for
problems in their infant, such as white plaques or thrush in their infant's mouth that can
occur when a portion of the maternal antibiotic passes into breast milk and causes an
overgrowth of fungal organisms in the infant. Antibiotics will not typically cause
jaundice. Irritability may or may not be because of the mother taking antibiotics.
Decreased sleep levels are not typically associated with maternal antibiotic use.
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11. The nurse instructs a patient on actions to prevent postpartum depression. During a
home visit, which observation indicates that instruction has been effective?
A) Patient complains of fatigue.
B) Patient appears disheveled and listless.
C) Patient is chatting on the telephone with a friend.
D) Patient is cleaning the kitchen while the baby naps.
Ans: C
Feedback:
Chatting on the phone with friends indicates that the patient is not becoming isolated
with baby care. This will help prevent the onset of postpartum depression. Fatigue,
listlessness, and trying to be perfect with cleaning are observations that could indicate
postpartum depression.
12. A postpartal patient is receiving heparin as treatment for thrombophlebitis. What should
the nurse instruct the patient about breastfeeding during this time?
A) Breastfeeding can continue.
B) The baby will need weekly blood work.
C) The effect of anticoagulants is counteracted by infant gastric juices.
D) All anticoagulants pass in breast milk so breastfeeding will have to stop.
Ans: A
Feedback:
A patient can continue to breastfeed while receiving heparin. The baby is not going to
need weekly blood work. Infant gastric juices do not impact the effect of anticoagulants.
Medications due affect breast milk; however, breastfeeding can continue while
receiving heparin.
13. A postpartal patient is being treated for a separated symphysis pubis. Which outcome
should the nurse identify when planning care for this patient?
A) Patient plans to return to work in 2 weeks.
B) Patient has coordinated child care assistance.
C) Patient picks up the infant from the bassinette.
D) Patient has a urine output of 30 ml per hour or greater.
Ans: B
Feedback:
With a separated symphysis pubis, bed rest and the application of a snug pelvic binder
to immobilize the joint may be necessary to relieve pain and allow healing. A 4- to
6-week period is necessary for healing to be complete. During this time, the patient
should avoid heavy lifting and may need to arrange for a person to help with child care
at home. The patient should not be lifting the baby. The patient needs at least 4 to 6
weeks to heal before returning to work. Urine output is not a measurement for a
separated symphysis pubis.
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14. A postpartum patient is diagnosed with a vaginal laceration. What intervention will the
nurse provide to the patient at this time?
A) Monitor vital signs every 30 minutes.
B) Insert an indwelling urinary catheter.
C) Provide stool softeners as prescribed.
D) Weigh vaginal packing to estimate blood loss.
Ans: B
Feedback:
An indwelling urinary catheter may be placed following a vaginal repair because the
packing causes such pressure on the urethra it can interfere with voiding. Vital signs do
not need to be monitored every 30 minutes. Stool softeners are not indicated for this
type of laceration. The packing is not removed for 24 to 48 hours.
15. During a home visit, a postpartum patient is complaining of a painful area on one breast.
The nurse notes a local area on one breast to be red and warm to touch. For which health
problem should the nurse plan care for this patient?
A) Mastitis
B) Breast cancer
C) Engorgement
D) Plugged milk duct
Ans: A
Feedback:
Mastitis is usually unilateral and the affected breast feels painful, appears swollen, and
reddened. The patient is postpartum and is breastfeeding. The nurse has no way of
knowing if the patient has breast cancer. Engorgement would affect both breasts
equally. Further diagnostic testing would be needed to diagnose a plugged milk duct.
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Chapter 26 Nursing Care of a Family With a High-Risk Newborn
1. The nurse is preparing formula for a preterm infant. Which type of formula will most
likely be prescribed for this patient?
A) Glucose water
B) 20 calories per ounce
C) 22 calories per ounce
D) Iron supplemented
Ans: C
Feedback:
The caloric concentration of formulas used for preterm infants is usually 22 calories per
ounce compared with 20 calories per ounce for a term baby. Glucose water will not
provide the infant with adequate calories. Iron supplementation will depend on
laboratory values.
2. The results of an amniocentesis conducted just prior to birth showed a fetus's
lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory
problem should the nurse anticipate providing care once the baby is delivered?
A) Alveolar collapse on expiration
B) Bronchial constriction from room air
C) Wheezing from excess fluid accumulation
D) Inspiratory constriction from air contaminants
Ans: A
Feedback:
Respiratory distress syndrome (RDS) of the newborn most often occurs in preterm
infants. Pulmonary surfactant is not present in preterm infant. Surfactant is needed to
prevent alveolar collapse upon expiration. RDS rarely occurs in mature infants. Dating a
pregnancy by sonogram and by documenting the level of lecithin in surfactant obtained
from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio are both important
ways to be certain that an infant is mature enough that RDS is not likely to occur. RDS
does not present as bronchial constriction from room air, wheezing from excess fluid
accumulation, or inspiratory constriction from air contaminants.
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3. Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which
nursing diagnosis is this intervention addressing?
A) Ineffective thermoregulation related to immaturity
B) Risk for imbalanced nutrition, less than body requirements
C) Risk for deficient fluid volume related to insensible water loss
D) Impaired gas exchange related to immature pulmonary functioning
Ans: A
Feedback:
Placing the preterm infant in a radiant heat warmer is addressing the diagnosis of
ineffective thermoregulation related to immaturity. Interventions regarding intake would
be appropriate for the diagnosis of risk for imbalanced nutrition. Interventions related to
intravenous fluids would be appropriate for the diagnosis of risk for deficient fluid
volume. Interventions related to oxygenation would be appropriate for the diagnosis of
impaired gas exchange.
4. The nurse manager of a labor and delivery unit is reviewing the skill set needed for the
nursing staff to meet the 2020 National Health Goals regarding preterm births. Which
skills should the manager validate that the nursing staff has to meet these goals? (Select
all that apply.)
A) Resuscitation at birth
B) Actions to prevent apnea
C) Identify characteristics of preterm labor
D) Actions to prevent maternal hypotension
E) Interventions to prevent intraventricular hemorrhage
Ans: A, B, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for preterm births by
teaching women the symptoms of preterm labor so that birth can be delayed until infants
reach term. Nurses also need to be prepared for resuscitation at birth of high-risk infants
and to plan developmental care that can help prevent conditions such as apnea and
intraventricular hemorrhage. Actions to prevent maternal hypotension would not help
achieve the 2020 National Health Goals for preterm labor.
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5. The nurse is planning developmental care for a preterm infant in the neonatal intensive
care unit. Which interventions should the nurse include in this patient's plan of care?
(Select all that apply.)
A) Provide audio stimulation with the use of music.
B) Stop procedures if the infant shows signs of distress.
C) Provide a nest with blankets to provide a sense of security.
D) Provide tactile stimulation by tickling the bottom of the feet.
E) Provide care consistently so the infant develops sleep/wake cycles.
Ans: A, B, C, E
Feedback:
Developmental care for a preterm infant in the neonatal intensive care unit should
include audio stimulation, stop procedures at signs of distress, provide a nest of blankets
for security, and provide consistent care so sleep/wake cycles develop. Tactile
stimulation should be provided by gentle back rubbing or massage. Tickling the feet
would be too harsh for this young patient.
6. While providing care, the nurse suspects that a preterm infant is developing respiratory
distress. What did the nurse most likely assess in this patient? (Select all that apply.)
A) Grunting
B) Nasal flaring
C) Intercostal retractions
D) Oxygen saturation 96%
E) Increasing respiratory rate
Ans: A, B, C, E
Feedback:
A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs
of obstruction or respiratory compromise in newborns. If these are present, undress the
baby's chest and look for intercostal retractions, which reflect the degree of difficulty the
newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits
and does not indicate respiratory distress.
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7. The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes
mellitus. Why should the nurse schedule routine blood glucose measurements for the
infant?
A) To detect rebound hypoglycemia
B) To determine insulin dosage to administer
C) To explain the effects of maternal hyperglycemia on the baby
D) To estimate the amount of calories to provide the infant through formula
Ans: A
Feedback:
Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the
early hours of life because large infants require large amounts of nutritional stores to
sustain their weight. If the mother had diabetes that was poorly controlled, the infant
would have had an increased blood glucose level in utero to match the mother's glucose
level; this caused the infant to produce elevated levels of insulin. After birth, these
increased insulin levels will continue for up to 24 hours of life, possibly causing
rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age
infants is not done to determine insulin dosage, to explain the effects of maternal
hyperglycemia on the baby, or to estimate the amount of calories to provide the infant
through formula.
8. A preterm infant is receiving oxygen to maintain respiratory status. When assessing this
patient, at which level should the nurse maintain oxygenation to prevent retinopathy of
prematurity?
A) 40 mmHg
B) 50 mmHg
C) 100 mmHg
D) 180 mmHg
Ans: C
Feedback:
When blood Po2 levels rise to higher than 100 mmHg, the risk of retinopathy of
prematurity increases. All preterm infants who receive oxygen must have blood oxygen
levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas
monitoring so the blood Po2 level can be kept within normal limits. Oxygenation at 40
mmHg or 50 mmHg is not sufficient for the infant. Oxygenation at 180 mmHg is too
high and can predispose the infant to develop retinopathy of oxygenation.
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9. The nurse instructs the parents of a newborn on actions to prevent sudden infant death
syndrome (SIDS). Which observation indicates that teaching has been effective?
A) Newborn is placed on the back to sleep.
B) Mother removes a pacifier from the baby's mouth.
C) The baby is on an every-2-hour formula-feeding schedule.
D) Parents signed a waiver refusing routine immunizations after birth.
Ans: A
Feedback:
Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to
60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding,
and having routine immunizations. Removing the pacifier, bottle feeding, and refusing
routine immunizations after birth all increase the infant's risk for experiencing SIDS.
10. A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid
balance. What did the nurse assess that supports this nursing diagnosis? (Select all that
apply.)
A) Specific gravity of 1.022
B) Respiratory rate of 40 breaths/min
C) Urine output less than 2 ml/kg/hr
D) Heart rate of 135 beats/min
E) Abdominal skin temperature of 96.9°F
Ans: A, C
Feedback:
An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests
inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min,
and abdominal skin temperature of 96.9°F are all within normal limits and do not
suggest inadequate fluid balance.
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11. The nurse is visiting the parents of a newborn diagnosed with periventricular
leukomalacia. Which statement indicates that the parents understand the newborn's
health problem?
A) “Once the infection clears up, the baby will be fine.”
B) “We will need to plan for special care to help with learning disabilities.”
C) “In a few months, more brain tissue will grow to fill in the hollow areas in the
brain.”
D) “In a few months, the baby will need to have physical therapy to train muscles to
work.”
Ans: B
Feedback:
Periventricular leukomalacia (PVL) is abnormal formation of the white matter of the
brain and is caused by an anoxic episode that interferes with circulation to a portion of
the brain. Phagocytes and macrophages invade the area to clear away necrotic tissue.
What is left is an abnormality in the white matter of the brain seen as a hollow space.
Once the condition has occurred, there is no therapy. Infants may die of the original
insult; they may be left with long-term effects such as learning disabilities or cerebral
palsy. The parents will need to plan for special care to help with the infant's learning
disabilities. The baby does not have an infection. Brain tissue will not grow to fill in the
hollow areas. There is no therapy for the condition, and there is no information to
support that physical therapy will be beneficial.
12. The nurse is caring for a small-for-gestational-age infant born to a drug-dependent
patient. For which manifestations should the nurse assess as evidence of withdrawal
symptoms in the newborn? (Select all that apply.)
A) Tremors
B) Convulsions
C) High-pitched cry
D) Constant movement
E) Sluggish respiratory rate
Ans: A, B, C, D
Feedback:
Infants of drug-dependent women tend to be small for gestational age. If the patient took
a drug close to birth, the infant may show withdrawal symptoms shortly after birth that
include tremors, convulsions, high-pitched cry, and constant movement. Respiratory
rate would be rapid and not sluggish.
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13. The nurse is instructing the parents of a preterm infant about the care the infant will
receive within the neonatal intensive care unit. What should the nurse include when
teaching the parents at this time? (Select all that apply.)
A) Bring in a small toy to be placed in the baby's bassinette.
B) Coordinate the times to visit the baby with the primary nurse.
C) Ask the nurse to explain equipment and the purpose for their use.
D) Write down the name of the baby's primary nurse and primary care provider.
E) Limit telephone calls to the care area since the nurses will not be able to respond.
Ans: A, B, C, D
Feedback:
When teaching parents of a newborn in the intensive care unit, the nurse should
encourage the parents to bring in a small toy to be placed in the baby's bassinette. The
parents should also coordinate the times to visit the baby with the primary nurse so that
quality time will be available. The parents should be reminded to ask questions about
equipment being used for the baby's care. The name of the primary nurse and primary
care provider should be recorded in case the parents have any questions. Telephone calls
are encouraged and should not be limited. The parents play an active part in the care of
the baby.
14. In which position should the nurse place a newborn to administer oxygen by bag and
mask?
A) Trendelenburg
B) On the back with the neck slightly flexed
C) On the back with the head slightly extended
D) Position is unimportant as long as the tongue is pulled forward.
Ans: C
Feedback:
If a newborn does not draw in a first breath spontaneously following gentle stimulation,
place the infant under a radiant heat warmer in a “sniffing” position, which is the head
slightly tipped back. Trendelenburg is not a recommended position since this increases
intracranial pressure. Flexing the neck could occlude the airway. The position is very
important; the tongue will not occlude the airway if the correct position is used.
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15. The nurse is preparing to administer surfactant (Survanta) 4 mg/kg every 12 hours for 2
days. The newborn weighs 2,300 g. How many milligram of the medication will the
newborn receive for all of the doses? (Numeric value only. Round to the nearest tenth
decimal point.)
Ans: 36.8 mg
Feedback:
The nurse needs to first convert the baby's weight of 2,300 g to kilogram by dividing by
1,000 or 2,300 / 1,000 = 2.3 kg. Then the nurse is to multiply the prescribed dose of 4
mg × 2.3 kg = 9.2 mg. This is the amount of medication the baby is to receive for each
dose. Since the baby is to receive one dose every 12 hours for 2 days or a total of four
doses, the nurse would then multiply the single dose amount of 9.2 mg × 4 = 36.8 mg.
The baby will receive 36.8 mg of the medication for the total four doses.
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Chapter 27 Nursing Care of the Child Born With a Physical or Developmental Challenge
1. The nurse is caring for an infant born with a myelomeningocele. Which should the nurse
assess in this patient?
A) Vision
B) Level of pain
C) Voiding pattern
D) Tonic neck reflex
Ans: C
Feedback:
: A myelomeningocele is the defect that is equated with “spina bifida” and is the most
common birth defect affecting the central nervous system. In a meningomyelocele, the
meninges protrude through the vertebrae and the spinal cord usually ends at the point of
protrusion. Motor and sensory function will be decreased or absent beyond this point.
The child will have loss of bowel and bladder control and urine, and stools will
continually dribble because of lack of sphincter control. This defect is not known to
affect vision. Assessing for pain is not a priority with this defect. This defect does not
affect the neck region of the spinal cord.
2. A newborn with esophageal atresia has just returned from surgery to place a
gastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for this
patient?
A) Risk for imbalanced nutrition
B) Risk for deficient fluid volume
C) Risk for impaired skin integrity
D) Risk for ineffective gas exchange
Ans: C
Feedback:
: The patient is at risk for impaired skin integrity related to gastrostomy tube insertion
site. Acidic gastric secretions can leak onto the skin from the gastrostomy site, leading
to skin irritation. The nurse should plan interventions to protect the skin by using a
cream or commercial skin protection system or consult with a wound, ostomy, and
continence therapy nurse to reduce the possibility of skin irritation and infection. With
the placement of the gastrostomy tube, the patient is at less risk for imbalanced nutrition
and deficient fluid volume. The gastrostomy tube will not affect the patient's gas
exchange.
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3. The nurse manager at a family clinic is identifying ways to address the 2020 National
Health Goals for the prevention of birth defects. Which action should the manager
encourage all staff to perform when caring for pregnant patients?
A) Avoid extreme physical activity and exercise.
B) Monitor daily intake of calcium and dairy products.
C) Stress the importance of taking prenatal folic acid as prescribed.
D) Ensure adequate hydration by drinking eight glasses of water each day.
Ans: C
Feedback:
: Nurses can help the nation achieve the 2020 National Health Goals by urging patients
to enter pregnancy with an adequate folic acid level. Extreme physical activity, exercise,
calcium, and water are not identified interventions to prevent birth defects in the
developing fetus.
4. The nurse is evaluating the outcome of teaching for a baby born with torticollis. Which
observation indicates that teaching has been successful?
A) The child looks in the direction of the affected muscle.
B) The child's shoulder of the affected muscle is elevated.
C) The child looks in the direction opposite of the affected muscle.
D) The child rolls onto the side to look from the direction opposite of the affected
muscle.
Ans: A
Feedback:
: To relieve torticollis, parents need to begin a program of passive stretching exercises,
laying the infant on a flat surface and rotating the head through a full range of motion.
Parents should always encourage the infant to look in the direction of the affected
muscle. They can encourage this by holding the child to feed in such a position the child
must look in the desired direction. If manual stretching is begun early and performed
consistently by parents, further treatment usually is not necessary. If extreme injury to
the muscle occurred, torticollis can lead to the continued elevation of one shoulder. Any
observations where the child is looking in the direction opposite of the affected muscle
indicates that teaching has not been successful.
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5. A newborn is diagnosed with a meconium plug. Which interventions should the nurse
prepare to provide to help resolve this health problem? (Select all that apply.)
A) Administration of a barium enema
B) Administration of a gastrografin enema
C) Administration of 5 ml of saline enema
D) Administration of 10 ml of tap water enema
E) Rectal instillation of acetylcysteine (Mucomyst)
Ans: A, B, C, E
Feedback:
: Treatment for a meconium plug includes the administration of 5 ml saline enema,
rectal instillation of acetylcysteine (Mucomyst), a gastrografin enema, and a barium
enema used to diagnose the disorder. A tap water enema should never be used in
newborns because it can cause water intoxication.
6. The nurse is assessing a 2-week-old infant who developed hydrocephalus. What should
the nurse expect to assess in this patient?
A) Excessive thirst
B) A soft, fretful cry
C) Hypothermia in the late afternoon
D) White sclera showing above the pupils
Ans: D
Feedback:
: As the fluid accumulation continues in hydrocephalus, the brow bulges forward, and
the eyes become “sunset eyes,” which means the sclera shows above the iris because of
upper lid retraction. Excessive thirst; soft, fretful cry; and hypothermia in the late
afternoon are not manifestations of hydrocephalus.
7. An infant with hydrocephalus has a ventriculoperitoneal shunt inserted. Immediately
following the procedure, which nursing action would best prevent decompression from
excessive CSF flow?
A) Elevating the infant's head 60 degrees
B) Keeping the head of the infant level with the body
C) Avoiding exercising the upper extremities during bathing
D) Positioning the infant with the head dependent to the body
Ans: B
Feedback:
: Following the surgery for the initial shunt insertion, the infant's bed should be left flat
or raised only about 10 degrees so the head remains level with the body. This is to
ensure that CSF does not flow too rapidly, possibly leading to tearing of cerebral
arteries or signs of too rapid decompression. The infant's head should not be raised 60
degrees. Upper extremity exercise is not contraindicated after placement of the shunt.
The patient's head should not be positioned dependent to the body.
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8. The nurse is preparing teaching for the parents of a newborn with a newly placed
ventriculoperitoneal shunt. What should the nurse include in this teaching? (Select all
that apply.)
A) Restrict the intake of fruit, vegetables, and fluid.
B) Expect to have the shunt replaced as the child grows.
C) Examine the site every day for signs of swelling or redness.
D) Notify the health care provider if the child develops a fever.
E) Observe the child for signs of increased intracranial pressure.
Ans: B, C, D, E
Feedback:
: Teaching for the parents of a child with a newly placed ventriculoperitoneal shunt
should include encouraging the intake of fruit, vegetables, and fluid to prevent
constipation; expecting to have the shunt replaced as the child grows; examining the site
every day for signs of redness or swelling; notifying the health care provider if the child
develops a fever; and observing for signs of increased intracranial pressure.
9. The nurse is checking a newborn for the presence of Ortolani and Barlow signs. For
which health problem are these assessments used?
A) Club foot
B) Cleft palate
C) Hip dysplasia
D) Tracheoesophageal fistula
Ans: C
Feedback:
: Ortolani and Barlow signs are used to assess for the presence of hip dysplasia. These
techniques assess for hip clicking and femoral head slipping. These signs are not used to
assess for club foot, cleft palate, or tracheoesophageal fistula.
10. A newborn is scheduled for casting to correct a talipes disorder. What should the nurse
instruct the parents about the height of the cast?
A) To the calf
B) Above the knee
C) At the level of the hip
D) Above the level of the waist
Ans: B
Feedback:
: For correction of a talipes disorder, a series of casts or braces are applied to gradually
mold the foot into good alignment. Although the disorder involves the ankle, the cast or
brace extends above the knee to ensure firm correction. The cast does not stop at the
calf. The cast also does not extend to the hip or to the waist.
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11. The nurse is planning care for a newborn with a cleft lip and palate scheduled for
surgery in a few weeks. For which health need will the nurse focus when planning this
patient's care?
A) Visual stimulation
B) Nutritional support
C) Prevention of pneumonia
D) Prevention of oral infection
Ans: B
Feedback:
: Before a cleft lip or palate is repaired, feeding the infant becomes a concern because
the infant has difficulty maintaining suction with a bottle or breast. Nutritional support
is of the highest priority at this time. Visual stimulation is not a concern for the infant
with a cleft lip and palate. Prevention of pneumonia and an oral infection are more
appropriate concerns after surgery has occurred.
12. The nurse is evaluating a mother's ability to catheterize her 2-year-old son. Which
observations indicate that teaching has been effective? (Select all that apply.)
A) Mother washes hands using warm, soapy water.
B) Mother coats the tip of the catheter with petroleum jelly.
C) Mother quickly removes the catheter once urine stops flowing.
D) Mother inserts the catheter into the urinary meatus one half of an inch.
E) Mother washes around the child's urinary meatus with warm, soapy water.
Ans: A, E
Feedback:
: When teaching on intermittent urinary catheterization, the nurse should instruct the
mother to use warm, soapy water to wash the hands and around the child's urinary
meatus. The mother should coat the tip of the catheter with a water-soluble lubricant and
not petroleum jelly. The catheter should be removed gently once urine stops flowing.
The catheter should be inserted approximately 3 in.
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13. An infant is prescribed oxybutynin chloride (Ditropan) for neurogenic bladder. What
should the nurse instruct the parents about this medication?
A) This medication has no adverse effects.
B) Check the child frequently for sweating.
C) Schedule appointments with the health care provider when necessary.
D) Provide the child with the medication when urinary output is sluggish.
Ans: B
Feedback:
: One adverse effect of oxybutynin chloride (Ditropan) is sweating. Sweating can cause
a rise in body temperature. The parents should be encouraged to restrict the child from
being exposed to high temperatures. Adverse effects of this medication include
drowsiness, dizziness, blurred vision, and sweating. Appointments with the health care
provider should be frequent so the effects of this medication can be evaluated. The
medication should be taken as prescribed and not only when the child's urinary output is
sluggish.
14. What health teaching should the nurse provide to the parents of a child recovering from
surgery to repair a cleft palate?
A) The child can expect to have chronic maxillary pain.
B) The child may have increased episodes of otitis media.
C) The child will have difficulty sensing the temperature of food.
D) The child may have a poor appetite from a decreased sense of taste.
Ans: B
Feedback:
: Surgery to correct a cleft palate changes the contour of the palate and the slope of the
eustachian tube to the middle ear. This can lead to a high incidence of middle ear
infection or otitis media because organisms are able to reach this area from the oral
cavity more readily than usual. The child is not expected to have chronic maxillary pain,
inability to sense the temperature of food, or a poor appetite from a decreased sense of
taste.
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15. The nurse is caring for a baby with esophageal atresia. Which situation during the
mother's pregnancy indicates that this health problem was developing?
A) Hydramnios
B) Oligohydramnios
C) A difficult second stage of labor
D) Bleeding at 32 weeks of pregnancy
Ans: A
Feedback:
: Esophageal atresia must be ruled out in any infant born to a woman with hydramnios
or excessive amniotic fluid. Normally, a fetus swallows amniotic fluid during
intrauterine life. With esophageal atresia, the fetus cannot swallow so the amount of
amniotic fluid grows abnormally large, leading to hydramnios. Oligohydramnios, a
difficult second stage of labor, or bleeding at 32 weeks of pregnancy does not indicate
that esophageal atresia was developing during fetal development.
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Chapter 28 Principles of Growth and Development
1. The nurse is planning to evaluate the development of a preschool-age child. On what
should the nurse focus when performing this evaluation?
A) Appetite
B) Current weight
C) Change in height
D) Ability to perform a skill
Ans: D
Feedback:
Development is measured by observing a child's ability to perform specific skills.
Growth is used to denote an increase in physical size such as height and weight.
Appetite is not used to evaluate growth or development.
2. A patient asks if a school-age child is going to be tall like others in the family. What
should the nurse explain as having the least impact on the child's ultimate height?
A) Participation in sports
B) Occupations of parents
C) Inherited genetic material
D) Ingestion of nutritious food
Ans: A
Feedback:
Although children cannot grow taller than their genetically programmed height
potential, their adult height can be considerably less than their genetic potential if their
environment hinders their growth. Environmental influences on height include
socioeconomic status or occupations of parents, genetic material inherited, and
availability and ingestion of nutritious foods. Participation in sports will not influence
the child's ultimate height.
3. The mother of several children is amazed that the youngest male child achieved toilet
training much earlier than the other children. What should the nurse explain as the
reason for this early development?
A) “He has exceptional intelligence.”
B) “He learned by watching your other children.”
C) “He needs testing because he is developing too quickly.”
D) “He most likely will wet the bed for many years to come.”
Ans: B
Feedback:
Children learn by watching other children so a youngest child who has many examples
to watch may excel in skills such as toilet training. The child did not become toilet
trained early because of exceptional intelligence. The child is not developing too
quickly. There is no way for the nurse to know if the child will wet the bed.
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4. A patient is concerned that the new baby is going to have a weight problem growing up
because other family members are obese. What should the nurse respond to this patient?
A) Restrict all fatty foods up until age 5 years.
B) Restrict fatty foods after the age of 10 years.
C) Do not restrict fatty foods until the age of 2 years.
D) Keep fat intake to less than 50% of total daily intake.
Ans: C
Feedback:
For children, fat intake does not need to be restricted for the first 2 years of life because
fat is necessary for myelination of spinal nerves. After the age of 2 years, fat intake can
be tailored to meet the guidelines of 30% total intake for both children and adults. The
patient should not restrict all fatty foods up until the age of 5 years or after the age of 10
years. Fat intake after the age of 2 years should be limited to 30% of total caloric intake.
5. During a home visit, the nurse observes an 8-year-old child pick up toys and place them
in the toy box. The child then looks to the mother who says, “Thank you for helping
me.” Which stage of Kohlberg's moral development is this child demonstrating?
A) Individualism
B) Maintenance of social order
C) Punishment/obedience orientation
D) Interpersonal relations of mutuality
Ans: D
Feedback:
In the stage of interpersonal relations of mutuality, the child will follow rules because of
a need to be a “good” person in their own eyes and in the eyes of others. The mother's
praise reinforces this behavior. In the punishment/obedience stage, the child does
“right” to avoid punishment. In the individualism stage, the child will carry out actions
to satisfy own needs rather than others. In the maintenance of social order stage, the
child will follow rules of authority figures as well as parents in an effort to keep the
“system” working.
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6. Which activity should the nurse encourage a new mother to perform to foster the
developmental tasks of a toddler according to Erikson's developmental stages?
A) Feed the child lunch.
B) Read the child a story every night.
C) Allow the child to pull a talking duck toy.
D) Have the child watch a puppet show on television.
Ans: C
Feedback:
The developmental task of the toddler is to learn autonomy versus shame or doubt.
Autonomy comes from the toddler's new motor and mental abilities. Children take pride
in the new things they can accomplish, and they want to do everything independently.
Pulling a talking duck toy will support the development of autonomy. Doing things such
as feeding, reading, and watching television does not foster autonomy in the toddler.
7. The nurse pours liquid medication from one tall container to a shorter container. How
would the preschool-age child interpret this exchange of the medication?
A) The amount of medicine is less.
B) The glass changed shape to accommodate the medicine.
C) Pouring medicine hurts it in some way because it changes.
D) The amount of medicine did not change, only the appearance.
Ans: A
Feedback:
The preschool-age child has not developed conservation or the ability to discern truth,
even though physical properties change. This is why the child will think that there is less
medicine in the shorter container. The preschool-age child will not interpret this action
as the glass changing shape or it is painful to pour medicine. An older child will
understand that the appearance of the medication changed but not the amount.
8. The nurse is preparing to assess a school-age child in the community clinic. Which
action supports the 2020 National Health Goals for growth and development of
children?
A) Helping the child with math homework
B) Measuring the child's height and weight
C) Talking about favorite television programs
D) Asking the child to name a favorite subject in school
Ans: B
Feedback:
Recognizing normal growth and development patterns of children helps to determine if
children are following normal development and when referrals are needed. Nurses are
the health care providers who interact with children and measure height and weight,
which are used to recognize developmental delays. Helping with homework, talking
about television, and identifying favorite subjects in school will not support the 2020
National Health Goals for growth and development of children.
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9. During a home visit, the nurse observes a mother prepare a bottle for an 18-month-old
child consisting of skim milk. Which nursing diagnosis should the nurse use to base
instruction for this mother?
A) Imbalanced nutrition
B) Health-seeking behaviors
C) Delayed growth and development
D) Readiness for enhanced family coping
Ans: A
Feedback:
The nursing diagnosis of imbalanced nutrition is appropriate because the child's fat
intake should not be restricted up until the age of 2 years. The developing body needs
fat to ensure development of the nervous system. The mother using skim milk for the
child's bottle does not indicate health-seeking behaviors, delayed growth and
development, or readiness for enhanced family coping.
10. Which observation by the nurse indicates that an adolescent's cognitive thinking is
developing at an expected level?
A) Adolescent says that all plastic remote controls break easily.
B) Adolescent asks the mother to provide the sharp item needed to cut meat.
C) Adolescent explains how working a part-time job will help pay for a car.
D) Adolescent tells the parent that the dog moved the bicycle into the driveway.
Ans: C
Feedback:
The adolescent is capable of abstract reasoning, which would be observed when the
adolescent explains how working a part-time job will help pay for a car. All plastic
remote controls breaking would be concrete thinking. Asking for a sharp item to cut
meat is an example of preschool-age thinking. Saying that the dog moved the bicycle
into the driveway is an example of preschool-age thinking.
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11. While in the waiting room, a child begins to cry when a toy has been taken from him.
The mother immediately hands the child another toy and the crying stops. How should
the nurse interpret the child's behavior?
A) Easily distractible
B) Short attention span
C) Negative mood quality
D) Extreme intensity of reaction
Ans: A
Feedback:
Children who are easily distracted or who can easily shift their attention to a new
situation are easy to care for. If they are crying over the loss of a toy, they can be
appeased by the offer of a different one. Attention span is the ability to remain interested
in a project or activity for an average length of time. Negative mood quality is when the
child is unhappy or whining. A child who has an intensity of rea situations with their
whole being. They cry loudly, thrash their arms, and have temper tantrums.
12. The nurse observes a mother telling a toddler that pasta and potatoes will make the child
fat. What should the nurse instruct the mother about these food items?
A) Toddlers need carbohydrates for brain function.
B) It is more important to restrict protein than carbohydrates.
C) No more than 30% of all food should be from carbohydrate sources.
D) The child should be instructed to restrict carbohydrates after the age of 5 years.
Ans: A
Feedback:
Carbohydrates are the main and preferred fuel of the body to supply energy and are
essential to the functioning of body systems, the neurologic system in particular. This
makes carbohydrates important to toddlers because their brain cells are actively
growing. Protein should not be restricted in the toddler. Carbohydrates should not be
restricted to 30% or after the age of 5 years.
13. The nurse observes an 8-month-old infant cry when the mother leaves the room. What
does this infant's behavior indicate to the nurse?
A) Confusion
B) Permanence
C) Reversibility
D) Assimilation
Ans: B
Feedback:
Gaining a concept of permanence also contributes to “8th-month anxiety,” a stage in
which infants continue to cry for their parents because they know their parents still exist
even when out of sight. Crying when the mother leaves the room does not indicate
confusion, reversibility, or assimilation.
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14. During a home visit, the nurse determines that a toddler has a difficult temperament.
What did the nurse observe in this toddler? (Select all that apply.)
A) Rhythmic
B) Withdrawing
C) Intense mood
D) Negative mood
E) Minimal adaptability
Ans: B, C, D, E
Feedback:
The child that has a difficult temperament is withdrawing, low in adaptability, intense,
and negative in mood. The child that has an easy temperament is rhythmic.
15. The nurse had instructed a mother on the importance of providing a toddler with a
balanced diet. Which observation during a home visit indicates that instruction has been
effective?
A) The child is eating a piece of cake and ice cream for lunch.
B) The mother prepares a scrambled egg for the toddler's breakfast.
C) The mother places a serving of fried finger foods on a plate for the child.
D) The child takes candy from a dish that is placed on the coffee table in the living
room.
Ans: B
Feedback:
A balanced diet will take into consideration all of the essential nutrients, vitamins, and
minerals needed for healthy growth and development of the toddler. A scrambled egg
for breakfast will provide the toddler with protein and help to regulate calcium and
phosphorous for good bone growth. Cake and ice cream, fried foods, and candy are not
nutritious foods for a toddler and indicate that instruction has not been effective.
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Chapter 29 Nursing Care of a Family With an Infant
1. The mother of a 3-month-old baby is concerned because the child is not able to sit
independently. What should the nurse respond to this mother's concern?
A) Most babies sit steadily at 3 months.
B) Most babies sit steadily at 4 months.
C) Most babies do not sit steadily until 8 months.
D) Sitting ability and the age of first tooth eruption are correlated.
Ans: C
Feedback:
An 8-month-old child can sit securely without any additional support. Babies are not
able to sit steadily at age 3 or 4 months. Sitting ability does not correspond with tooth
eruption.
2. During an assessment, the nurse determines that a 3-month-old baby has a Moro reflex.
What does this finding indicate to the nurse?
A) It usually lasts until 9 months.
B) It will persist until the age of 1 year.
C) Most 3-month-olds still have a Moro reflex.
D) If present at 3 months of age, a neurologic exam is needed.
Ans: C
Feedback:
The Moro reflex will begin to fade at age 5 months and disappear by age 6 months. A
Moro reflex at age 9 months or 1 year indicates the need for a neurologic examination.
3. The nurse is planning an educational seminar for community members that focus on the
2020 National Health Goals to promote health during the infant year. What should the
nurse include in this seminar? (Select all that apply.)
A) Using infant car seats
B) Placing infants on back to sleep
C) Continuing breastfeeding for 6 months
D) Introducing solid food by age 6 months
E) Receiving immunizations after the age of 1
Ans: A, B, C
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to promote health
during the infant year by educating parents about the importance of using infant car
seats, continuing exclusive breastfeeding for 6 months, and instigating measures to
prevent SIDS such as placing infants to sleep on their backs. The introduction of solid
food would occur after the age of 6 months. Immunizations are provided throughout the
infant year.
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4. What should the nurse instruct a parent to help a child complete Erikson's
developmental task during the infant period?
A) Respond to the child's needs consistently.
B) Keep the child stimulated with many toys.
C) Talk to the child at a special time each day.
D) Expose the child to many caregivers to help learn variability.
Ans: A
Feedback:
Consistently responding to an infant's needs helps to build a sense of trust, which is
Erikson's developmental task during the infant period. Stimulation with toys, talking at a
special time each day, and exposing to many caregivers will not help the child develop a
sense of trust.
5. The nurse is visiting a mother who has a 3-month-old infant. Which anticipatory
guidance information should the nurse provide to the mother at this time?
A) The child will have a fear of strangers.
B) The child will experience many moody periods.
C) The child will expect things to be done a certain way.
D) The child should be able to turn over onto the back at age 4 months.
Ans: D
Feedback:
Infants typically turn over from the front to back at age 4 months. Fear of strangers will
not occur until 7 months. The nurse has no way of knowing the infant's temperament to
determine that the child will be moody or when the child will expect things to be done a
certain way.
6. The nurse is assessing an infant who is being breastfed. Which observation regarding
the infant's stools is expected?
A) Fewer stools
B) Stool will be soft.
C) Stool will be hard.
D) Stool will have a strong odor.
Ans: B
Feedback:
Stools of breastfed infants are generally softer than those of formula-fed infants. Stools
of breastfed infants are not fewer in number, hard, nor have a strong odor.
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7. The nurse is identifying outcomes for care provided to a new mother whose infant
continues to spit up after feedings. Which outcome would be the most appropriate?
A) The baby will have forceful episodes of vomitus only once a day.
B) The baby will have less episodes of spitting up after sitting upright after a feeding.
C) The baby will spit up a large amount of vomitus only after the last feeding of the
day.
D) The baby will have fewer episodes of spitting up when the type of formula is
changed.
Ans: B
Feedback:
Sitting a baby in an infant chair for a half an hour after a feeding can help reduce
spitting up. Forceful episodes of vomitus and vomiting large amounts after feedings
should be reported to the health care provider. Changing the formula will not impact the
amount of spitting up the baby.
8. The nurse is assessing a 2-month-old formula-fed infant who is experiencing colic.
Which type of bowel movements should the nurse expect to occur with this health
problem?
A) Hard and lumpy
B) Yellow and semisoft
C) Foul smelling and bulky
D) Loose and mucus-streaked
Ans: B
Feedback:
With colic, bowel movements are normal. For an infant who is formula-fed this means
the stool will be yellow and semisoft. Colic does not affect the type of bowel movement
so changes in the stool such as hard and lumpy, foul smelling and bulky, and loose and
mucus-streaked should be reported to the health care provider.
9. The nurse is visiting a mother who has a 3-month-old infant that has been hospitalized
for cardiac problems. Which nursing diagnosis should the nurse use to guide care for
this family at this time?
A) Health-seeking behaviors related to adjusting to parenthood
B) Risk for impaired parenting related to hospitalization of infant
C) Disturbed maternal sleep pattern related to infant's feeding schedule
D) Deficient knowledge related to normal infant growth and development
Ans: B
Feedback:
The diagnosis appropriate for the family whose infant has been hospitalized would be
risk for impaired parenting related to hospitalization. There is no evidence to suggest
that the mother is not adjusting to parenthood. There is no information about the infant's
feeding schedule. There is no information to suggest the mother has a knowledge deficit
regarding normal infant growth and development.
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10. A new mother asks the nurse when toothbrushing should begin for the baby. Which
response is the most appropriate for the nurse to make at this time?
A) Now
B) At the age of 12 months
C) When solid food is eaten
D) When the first tooth appears
Ans: A
Feedback:
Toothbrushing can begin even before teeth erupt by rubbing a soft washcloth over the
gum pads. This eliminates plaque and reduces the presence of bacteria, creating a clean
environment for the arrival of first teeth. Dental care should begin before the age of 12
months, before solid food is eaten, and before the first tooth appears.
11. The mother of a 4-month-old infant is concerned that the baby does not always want to
take a bottle. What should the nurse instruct the mother about feeding the baby?
A) Ensure the environment is quiet during mealtime.
B) Happy and healthy babies do not always eat well.
C) Force the infant to take a bottle when it is time to do so.
D) Refusing a bottle means the child is ill and needs to be seen by the health care
provider.
Ans: A
Feedback:
If infants are fatigued or overstimulated, they also may not eat well. Providing a quiet
environment away from distractions before mealtime might be the solution to this
problem. Healthy happy babies will be hungry at mealtime and will eat. The mother
should not force the baby to take a bottle when it is time to do so. Refusing a bottle may
mean that the baby is tired, distracted, or ill. The baby does not always need to be seen
by a health care provider when a bottle is refused.
12. A new mother asks the nurse what she should look for when the baby starts to teethe.
What should the nurse explain to the mother?
A) The child's gum line will be tender.
B) The child will have a high temperature.
C) The child will not play or eat for 2 days.
D) The child will be constipated for 2 days.
Ans: A
Feedback:
Gums are sore and tender before a new tooth breaks the surface. As soon as the tooth is
through, the tenderness passes. A high temperature is not a normal expectation with
teething and should be reported to the health care provider. The child may resist
chewing because of the sore gum; however, it may not last for 2 days. Playing may or
may not be affected. Constipation is not an expectation with teething.
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13. During a home visit, the nurse observes a 9-month-old child bang his head against the
headboard of the crib at naptime. What should the nurse explain to the mother about this
observation?
A) The child is eating too much protein.
B) The child is not getting enough to eat.
C) This action is normal up until preschool age.
D) The child needs to be seen immediately by a health care provider.
Ans: C
Feedback:
Head banging that begins during the second half of the first year of life and continuing
through to the preschool period, associated with naptime or bedtime, and lasting under
15 minutes can be considered normal. Children use this measure to relax and fall asleep.
Head banging does not mean that the child is eating too much protein or is not getting
enough to eat. The child does not need to be seen immediately by a health care provider.
14. The nurse observes a new mother provide a bath to her 9-month-old baby. Which
observation indicates that the experience is positive for both mother and infant?
A) The baby is crying and screaming.
B) The baby is reaching for the mother.
C) The baby is moving the arms and hand and smiling.
D) The baby is trying to keep the legs from touching the water.
Ans: C
Feedback:
Bath time should be fun for an infant and can serve many functions. Especially during
the second half of the first year, a child enjoys poking at soap bubbles on the surface of
the water or playing with bath toys. Bath time also helps an infant learn different
textures and sensations and provides an opportunity to exercise and kick as well as a
good opportunity for a parent to touch and communicate with the child. Crying,
screaming, reaching for the mother, and trying to avoid touching the water indicates that
the bath experience is not positive for the baby or the mother.
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15. The nurse is concerned that a 9-month-old baby is gaining too much weight. What
should the nurse instruct the parents to help control the baby's weight gain?
A) Use skim milk for feedings.
B) Provide whole-grain cereal for one feeding.
C) Provide one bottle a day of diluted gelatin mix.
D) Feed the baby a serving of pudding once a day.
Ans: B
Feedback:
A way to prevent obesity is to add a source of fiber such as whole-grain cereal to the
infant's diet. This prolongs the stomach-emptying time and helps reduce food intake.
Nonfat milk should not be given because it contains little essential fatty acids and will
not ensure cell growth. The baby should not be given refined sugars such as diluted
gelatin or pudding because this will encourage weight gain.
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Chapter 30 Nursing Care of a Family With a Toddler
1. When assessing the oral cavity of a 2.5-year-old toddler, which finding is expected?
A) 12 deciduous teeth
B) 20 deciduous teeth
C) 16 deciduous and 2 permanent teeth
D) 6 deciduous and 12 permanent teeth
Ans: B
Feedback:
All 20 deciduous teeth are generally present by 2.5 to 3.0 years of age.
2. The nurse is preparing a community educational program for the parents of toddlers.
Which topics should the nurse include that address the 2020 National Health Goals for
safety? (Select all that apply.)
A) Using age-appropriate car seats
B) Securing poisonous items out of reach
C) Eliminating lead-based paint in the home
D) Removing pets from the home environment
E) Obtaining foot stools for use during toilet training
Ans: A, B, C
Feedback:
The 2020 National Health Goals for toddlers focus on safety. The nurse can help the
nation achieve these goals by educating parents about the importance of using car seats
and childproofing the home against poisoning and lead poisoning. The National Health
Goals do not address pets in the home. Foot stools for toilet training are not a safety
concern.
3. The parents of a toddler want to assist the child achieve the developmental task of
autonomy. Which approach should the nurse suggest to the parents?
A) Teach the child how to count.
B) Allow the child to make simple decisions.
C) Give the child small household chores to do.
D) Urge the child to put on clothes independently.
Ans: B
Feedback:
To develop a sense of autonomy is to develop a sense of independence. A healthy level
of autonomy is achieved when parents are able to balance independence with
consistently sound rules for safety. Allowing the child to make simple decisions helps
the child achieve autonomy in a safe setting. Teaching how to count will not help
develop autonomy in the child. Providing the child with chores will not develop
autonomy. The child is not developmentally prepared to be able to put on clothes
independently.
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4. A mother is concerned that her 2-year-old child is having seizures when he holds his
breath until he passes out when he wants something his mother does not want him to
have. What should the nurse respond to this mother's concern?
A) Seizures rarely occur in toddlers.
B) With seizures, cyanosis rarely develops.
C) Seizures are not provoked; temper tantrums are.
D) Seizures typically occur with fever; temper tantrums do not.
Ans: C
Feedback:
Some children hold their breath as part of a temper tantrum until they become cyanotic.
Breath holding occurs when a child is provoked; the child develops a distended chest,
often has air-filled cheeks, and shows increasing distress as the body registers oxygen
want. A seizure cannot be provoked. Seizures can occur in all ages. Cyanosis can occur
with seizures. Seizures can occur in those with neurologic problems and not just with a
fever.
5. The nurse had instructed the family of a toddler on home safety during a previous visit.
During this current visit, what observation indicates that instruction has been effective?
A) Prescribed medication sitting on countertop
B) House plant on a small table next to the sofa
C) Small bowl of mixed nuts on the coffee table
D) All windows in the home have locked screens.
Ans: D
Feedback:
To prevent falls, the parents should keep the house windows closed or keep secure
screens in place. Prescribed medication should be stored in a locked cabinet and not left
out on a table because this could cause accidental poisoning. House plants should not be
within reach of the toddler because this could cause an accidental poisoning or injury if
the plant is pulled on top of the child. Nuts could cause accidental choking and should
not be within the child's reach.
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6. The parents of a toddler plan to begin toilet training. Which instruction should the nurse
provide to the parents at this time?
A) Toilet training is a 12-month process.
B) Bowel training is easier than urine training.
C) All children should be toilet trained by age 2 years.
D) Children can remain dry during the night before they can do so during the day.
Ans: B
Feedback:
Training should begin with defecation training because this is an easier concept for the
child to grasp. There is no time limit regarding the amount of time it takes to toilet train
a toddler. Even though theoretically a child can begin toilet training once able to walk,
the child needs to reach specific milestones before being able to successfully toilet train.
Children are more likely to remain dry during the day than during the night.
7. The nurse is determining a toddler's language development. What is an expected finding
for language development in a 2-year-old?
A) Able to count out loud to 20
B) Speaks 20 nouns and 4 pronouns
C) Speaks two words plus “ma-ma” and “da-da”
D) Speaks in two-word sentences using a noun and a verb
Ans: D
Feedback:
A 2-year-old child should be speaking in simple two-word sentences using a noun and a
verb. Any 2-year-old child who does not talk in two-word, noun–verb simple sentences
needs a careful assessment to determine the cause because this is beyond a point of
normal development. Counting is not an expectation for a 2-year-old child. The child
will not be able to speak 20 nouns and 4 pronouns.
8. The nurse observes a toddler riding a tricycle and decides that the parents need
additional safety education. What did the nurse observe?
A) Toddler wearing a helmet
B) Toddler wearing long pants
C) Toddler wearing tennis shoes
D) Toddler not wearing a helmet
Ans: D
Feedback:
Toddlers need to wear a helmet as soon as they begin riding a tricycle. Parents are not as
conscientious about using helmets as they are for bicycle riding so this is an area where
health teaching is necessary. Wearing a helmet would be expected, and the nurse would
not need to provide additional safety education for the parents. Long pants and tennis
shoes do not pose a safety issue.
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9. The mother of a toddler is frustrated because no matter what she asks of the child, the
response is “no.” What can the nurse suggest to the mother to assist with this problem?
A) Pretend she does not hear the child.
B) Ask no further questions to the child.
C) Tell the child to never to say “no” again.
D) Give the child secondary, not primary, choices.
Ans: D
Feedback:
A toddler needs experience in making choices, and to provide the opportunity to do this,
a parent could give a secondary choice. Pretending not to hear the child, asking no
further questions, and telling the child to never say “no” again will not help with the
toddler's obstinacy.
10. The mother of a toddler is frustrated because the toddler insists on brushing his own
teeth and being left alone in the bathtub. What advice should the nurse provide to the
mother about these expectations?
A) Helping with toothbrushing encourages autonomy.
B) It is unusual for a 2-year-old to have such strong opinions.
C) The mother should continue to give full care in all aspects.
D) Leaving alone in the bathtub is a good way to encourage autonomy.
Ans: A
Feedback:
Toddlers need a toothbrush they recognize as their own. Toward the end of the toddler
period, they can begin to do the brushing themselves under supervision; although,
almost all children need some supervision until about age 8 years. It is not unusual for a
toddler to have opinions and want to do things themselves. The mother needs to permit
the child to perform autonomous acts with supervision. The child is too young to be
permitted in the bathtub alone. This is a safety hazard.
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11. The mother of a toddler is concerned because the child has taken the wheels off of a toy
truck and placed them in a sandbox as stepping stones to walk. What should the nurse
explain about this child's behavior?
A) This is assimilation.
B) The child does not like toy trucks.
C) The number of toys should be limited.
D) This is abnormal and needs to be evaluated.
Ans: A
Feedback:
At the end of the toddler period, children enter a second major period of cognitive
development termed preoperational thought and begin to use a process termed
assimilation. This is when the child learns to change a situation and is what causes
toddlers to use toys in the “wrong” way such as taking the wheels off of a truck and
using them as stepping stones. The child has changed the toy's use to fit his or her
thoughts or used assimilation. This behavior does not mean that the child does not like
toy trucks. The number of toys does not need to be limited. This behavior is not
abnormal but expected.
12. The mother of a toddler observes the child play next to another child but not with the
child. What should the nurse explain to the mother about this type of play behavior?
A) This is peer play and is abnormal.
B) This is parallel play and is expected.
C) This is premature play and should be stopped.
D) This is adjacent play and is only seen in school-age children.
Ans: B
Feedback:
All during the toddler period, children play beside children next to them, not with them.
This side-by-side play called parallel play is not unfriendly but is a normal
developmental sequence that occurs during the toddler period. This is not peer, adjacent,
or premature play. This behavior is not abnormal, does not need to be stopped, and is
not seen in school-age children.
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13. The nurse is preparing to assess a toddler during a routine health maintenance visit.
Which assessment will the nurse perform to determine the child's growth milestone?
A) Blood pressure
B) Urine specimen
C) Hemoglobin level
D) Height and weight
Ans: D
Feedback:
Growth milestones are assessed at every health maintenance visit and are determined by
measuring height and weight. Blood pressure does not assess a growth milestone. A
urine specimen would be done at specific times. A hemoglobin level would be
determined during specific times. Urine specimens and hemoglobin levels do not
measure growth milestones.
14. A mother brings a 15-month-old child to the clinic for a routine health maintenance
visit. Which immunization should the nurse prepare to administer to this child?
A) MMR
B) Rinne test
C) Oral polio
D) Hepatitis A
Ans: A
Feedback:
The measles-mumps-rubella (MMR) vaccine is administered at either the 12-month or
15-month visit. Rinne test is not an immunization but rather a test for hearing. The oral
polio vaccination is not listed as an immunization needed for toddlers. Hepatitis A
vaccination is given at either the 12-month or 18-month visit.
15. The mother of a 2-year-old child tells the nurse that she is constantly scolding the child
for having wet pants. The child was toilet trained at 12 months, but since walking, the
child wets all of the time. Which nursing diagnosis should the nurse use guide
instruction for the mother?
A) Total urinary incontinence related to delayed toilet training
B) Excess fluid volume related to inability to control urination
C) Ineffective coping related to lack of self-control of 2-year-old
D) Deficient parental knowledge related to inappropriate method for toilet training
Ans: D
Feedback:
The mother is having difficulty understanding the principles of toilet training. The
diagnosis of deficient parental knowledge about toilet training is the most appropriate
for the nurse to use to guide instruction for the mother. The child is not experiencing
total urinary incontinence. The child does not have an excess in fluid volume. The
mother is not demonstrating ineffective coping.
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16. The parents of a toddler are worried that the child is not eating enough because food is
always left on the child's plate. What should the nurse encourage the parents to do?
A) Place smaller amount on the child's plate.
B) Reinforce that the child is to eat everything on the plate.
C) Discipline the child for not eating by removing a toy from play.
D) Feed the child if refusing to eat the food on the plate independently.
Ans: A
Feedback:
Because the actual amount of food eaten daily varies, the parents should be instructed to
place a small amount of food on a plate and allow their child to eat it and ask for more
rather than serve a large portion the child cannot finish. Cleaning a plate gives a child a
feeling of independent functioning, whereas leaving food uneaten suggests parents
expected something more. Allowing self-feeding is a major way to both strengthen
independence in a toddler and improve the amount of food consumed. Most toddlers
insist on feeding themselves and generally will resist eating if a parent insists on feeding
them. An individual child may react to repeated attempts at being fed by refusing to eat
at all. The child does not need discipline.
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Chapter 31 Nursing Care of a Family With a Preschool Child
1. The nurse is identifying outcomes for a family with a preschool-age child who has
broken fluency. Which outcome would be the most appropriate for this family?
A) The parents will not call attention to the child's broken fluency.
B) The mother will encourage the child to practice speaking in the home.
C) The other children will help the child by finishing words and sentences.
D) The mother will correct the child only when other family members are absent.
Ans: A
Feedback:
Calling attention to broken fluency can make the situation worse. The child should not
be encouraged to speak if he or she does not want to. The parents should intercept any
children who desire to finish the child with broken fluency's words or sentences. The
child should not be punished or corrected for broken fluency because this is a normal
part of speech development.
2. The nurse is helping parents develop the developmental task of initiative in their
preschool-age child. Which activity should the nurse suggest the parents implement?
A) Teach the child street-crossing safety.
B) Help the child learn how to follow rules.
C) Allow the child to experiment with molding clay.
D) Provide the child with clothes that snap rather than button.
Ans: C
Feedback:
To gain a sense of initiative, preschoolers need exposure to a wide variety of play
materials so they can learn as much about how things work as possible. The parents
should be urged to provide play materials that encourage creative play such as modeling
clay. Any experience with free-form play is helpful. Street-crossing safety, following
rules, and providing clothes that snap will not support the developmental task of
initiative as much as providing a substance to experiment during play.
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3. The nurse is preparing an educational program for parents of preschool-age children to
promote personal safety. Which information should the nurse include in this program?
(Select all that apply.)
A) Reducing the intake of fast-food items
B) Limiting exposure to household chores
C) Chewing food thoroughly before swallowing
D) Explaining who police are and what they look like
E) Teaching to never talk with or accept a ride from a stranger
Ans: D, E
Feedback:
To promote personal safety in the preschool-age child, the nurse should instruct families
to explain the role and purpose of police to the child and teach to never talk to or accept
a ride from a stranger. Reducing the intake of fast-food items will help with weight
control. Limiting exposure to household chores has no identified value. Chewing food
thoroughly before swallowing can help with digestion and weight control.
4. The nurse is caring for a preschool-age child who needs a CT scan. Which action should
the nurse use to best prepare the child for this diagnostic test?
A) Tell the child to follow directions to avoid being hurt.
B) Help the child to pretend that the CT scan machine is a camera.
C) Explain that the child must behave because the technician is busy.
D) Tell the child that the CT scan is a picture of the dark parts inside the body.
Ans: B
Feedback:
Because preschoolers' imagination is so active, this leads to several fears such as fear of
the dark and mutilation. The nurse needs to help the child understand that the CT
scanner is like a camera to take pictures of the body parts. Threatening the child to
follow directions or becoming hurt plays into the child's fear of mutilation. Telling the
child to behave creates a fear of punishment. Telling the child that the CT scan is a
picture of the body's dark parts plays into the child's fear of the dark.
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5. Which type of play should the nurse encourage for a preschool-age child that is
hospitalized?
A) Playing an electronic handheld game
B) Dressing in the mother's coat to play house
C) Turning out the lights to play hide and seek
D) Planting flower bulbs that can be watched growing next spring
Ans: B
Feedback:
Preschool-age children have active imaginations and dressing up to play house would be
an appropriate play activity for the nurse to encourage. The child's fine motor skills are
not developed to play an electronic handheld game. Children of this age are afraid of the
dark so turning out the lights to play hide and seek is not appropriate. Planting flower
bulbs is an activity that is too long-term for this age range.
6. Which immunization should the nurse plan to administer to a preschooler during a
health maintenance visit?
A) DTaP
B) Influenza
C) Hepatitis B
D) Tetanus booster
Ans: B
Feedback:
Influenza vaccination would be administered annually. The diphtheria, pertussis, and
tetanus (DTaP) vaccination should be provided before the child starts school. Hepatitis
B and tetanus booster are not identified as vaccinations appropriate for this age group.
7. The mother of a female preschool-age child is concerned that the child is developing an
unhealthy attachment to her father. About which behavior should the nurse instruct the
mother?
A) Electra complex
B) Oedipus complex
C) Freudian complex
D) Sexual identification complex
Ans: A
Feedback:
An Electra complex is the attachment of a preschool girl to her father. This phenomenon
in preschoolers is a normal part of maturing. Oedipus complex is the attachment of a
preschool-age boy to his mother. There is not one specific Freudian complex. There is
not an identified sexual identification complex.
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8. A preschool-age child tells the nurse about an imaginary friend. The parents are
concerned because the child refuses to do anything without the friend's help. Which
nursing diagnosis is most applicable for the family?
A) Compromised family coping related to abnormal behavior of child
B) Disturbed thought processes related to deep-set psychological need
C) Parental anxiety related to lack of understanding of childhood development
D) Social isolation related to unwillingness to relate except through imaginary friend
Ans: C
Feedback:
The parents need to understand that the child's behavior is not uncommon. Imaginary
friends are common in the preschool-age child. The child's behavior is not abnormal.
The child does not have a deep-set psychological need. The child is not at risk for social
isolation.
9. The nurse is observing the behavior of a preschool-age child and becomes concerned.
Which observation suggests that the child's thinking is inconsistent with normal
preschooler growth and development?
A) Refusing to play with “real” children
B) Refusing to go to bed without the friend
C) Insisting that an imaginary friend have dinner with the family
D) Insisting that an imaginary friend watch television with the child
Ans: A
Feedback:
Many preschoolers have an imaginary friend who plays with them. Imaginary friends
are a normal, creative part of the preschool years and can be invented by children who
are surrounded by real playmates as well as by those who have few friends. As long as
the child has exposure to real playmates and imaginary, do not take center stage in the
child's life or prevent them from socializing with other children; the imaginary friend
should not pose a problem. Refusing to go to bed without the friend, having the friend
eat dinner with the family, and watching television with the imaginary friend are all
acceptable behaviors by the preschool-age child.
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10. During an assessment, a preschool-age child tells the nurse about having 12 siblings.
The nurse is aware that the child has two older brothers. What should the nurse respond
to this child?
A) “I guess you don't know much about counting yet.”
B) “Don't lie to me. That's never a nice thing to do to someone.”
C) “Does it make you feel more important when you add on brothers?”
D) “That is a good pretend answer but tell me the names of the brothers you really
have.”
Ans: D
Feedback:
Stretching stories to make them seem more interesting is a phenomenon frequently
encountered in preschoolers. This kind of storytelling should not be encouraged. The
child should be helped to separate fact from fiction. The nurse should ask the child to
say the names of the brothers the child really has. The nurse should not insult the child's
counting ability. The nurse should not accuse the child of lying or making the child
seem more important by having more brothers.
11. A community health center is planning a seminar about the 2020 National Health Goals
for preschool-age children. Which topics should be included in this seminar to address
safety? (Select all that apply.)
A) Protection against secondhand smoke
B) Providing helmets before riding a bicycle
C) Using appropriate restraints in motor vehicles
D) Removing houseplants from easy to reach areas
E) Posting the telephone number of the poison control agency
Ans: A, B, C
Feedback:
The 2020 National Health Goals for preschool-age children focus on safety and include
protecting preschoolers against secondhand smoke, using recommended automobile
restraints, and fitting children with helmets before beginning bicycle riding. Removing
houseplants and posting the telephone number of the poison control agency would be
appropriate for families with toddlers.
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12. The mother of a preschool-age child is pregnant and wants to enroll the child in a child
care program. When should the nurse suggest that the child be enrolled in this program?
A) By 4 years of age regardless of the pregnancy
B) Now after explaining that the new sibling will take up the mother's time
C) Three months before the baby is born, after the mother stresses that he is growing
up
D) Immediately after the baby is born so that the child will feel less jealous and more
secure
Ans: C
Feedback:
If children are to start preschool or child care, it's best if they can do so either before the
new baby is born or 2 or 3 months afterward. That way, children can perceive starting
school as a result of maturity and not of being pushed out of the house by the new child.
There is no time limit about when a child should start preschool. The mother should not
explain to the child that the new baby will be taking up all of the mother's time.
13. The parents of a preschool-age child are investigating child care centers to enroll the
child. What should the nurse review with the parents prior to them making a decision?
(Select all that apply.)
A) Ask about the child–staff ratio.
B) Ask about the center's payment plan.
C) Find out if parents can visit at any time.
D) Find out how long the center has been in operation.
E) Ask about the center's licenses and compliance with regulations.
Ans: A, C, D, E
Feedback:
When investigating child care centers, the nurse should counsel the parents to find out
about the child–staff ratio, parental visiting hours, the time the center has been in
operation, and compliance with licenses and regulations. The payment plan might be
important to the parents; however, it should not be the sole factor in making a decision
about a child care center.
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14. The nurse instructs a mother on actions to prevent sibling rivalry between a
preschool-age child and a newborn. Which observation indicates that instruction has
been effective?
A) Mother sleeps while the newborn is sleeping.
B) Mother asks if the preschool-age child likes the new baby.
C) Mother sets aside afternoon time for the preschool-age child while the baby naps.
D) Mother suggests family not bring gifts to the preschool-age child until behavior
changes.
Ans: C
Feedback:
To help reduce sibling rivalry, the mother should set aside afternoon time for the
preschool-age child while the baby naps. Sleeping when the baby sleep, asking if the
preschool-age child likes the baby, and limiting gifts to the preschool-age child until
behavior changes will promote sibling rivalry.
15. The parents of a preschool-age child want to begin preparing the child to attend school.
What should the nurse suggest the parents discuss with the child to help with this
preparation?
A) Point out how to go to school.
B) Talk about school as an enjoyable experience.
C) Warn about how many rules there will be in school.
D) Encourage working on projects lying on the floor so school tables will be
appreciated.
Ans: B
Feedback:
If school is discussed as something to look forward to, as an adventure that will be
satisfying and rewarding, a child comes to look forward to it as a positive experience.
Pointing out how to get home from school might be more important than how to get to
school. Warning about rules and expecting to work on the floor may cause the child to
view school as punishment.
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Chapter 32 Nursing Care of a Family With a School-Age Child
1. While planning care for a 7-year-old patient, the nurse reminds the parents that children
at this age are experiencing the “eraser” year. What does this mean?
A) The child wants to perform well.
B) The child believes in magical thinking.
C) The child is learning to write during this year.
D) The child tends to “erase” misdeeds or lie excessively.
Ans: A
Feedback:
Seven-year-olds concentrate on fine motor skills, and this year has been called the
“eraser” year because children are never quite content with what they have done. They
set too high a standard for themselves and then have difficulty performing at that level.
Toddlers believe in magical thinking. The child has already learned how to write. The
eraser year does not mean that the child is erasing misdeeds or lying.
2. The school nurse is reviewing content to include in an assembly planned for school-age
children that focuses on the 2020 National Health Goals for safety. What should the
school nurse include in this presentation? (Select all that apply.)
A) Encourage the children to play outdoors and get exercise everyday.
B) Stress the need to sit in age-appropriate seats in cars and wear seatbelts.
C) Remind children how important it is to brush the teeth and see the dentist.
D) Explain how important it is for children to wear safety helmets when bicycling.
E) Offer suggestions to ensure an adequate intake of fruits and vegetables each day.
Ans: B, D
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals by urging children to
follow safety rules for automobile and bicycle safety. Playing outdoors, getting exercise,
and having an adequate intake of fruits and vegetables would be appropriate for
nutritional goals. Brushing the teeth and seeing the dentist would be appropriate for
health promotion goals.
3. The nurse is caring for a 9-year-old patient in the hospital. Which project should the
nurse provide to help this child achieve the developmental task of industry?
A) Sew a purse that will take one afternoon.
B) Watch favorite programs on the television.
C) Design a puppet show that will take 2 weeks to plan.
D) Work on a scrapbook that will take 3 weeks to complete.
Ans: A
Feedback:
Hobbies and projects are best enjoyed if they are small and can be finished within a
short time. Most school-age children prefer putting together something fairly simple
rather than something that is more complicated because the complicated one will delay
the reward, and the child may become bored and never complete it. Watching television
does not help the child achieve the developmental task of industry.
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4. While making a visit to the home of a family with a school-age child, the nurse observes
a hunting rifle leaning against the wall in the dining room. Which nursing diagnosis
should the nurse use to guide interventions for the family at this time?
A) Anxiety
B) Risk for injury
C) Health-seeking behaviors
D) Readiness for enhanced parenting
Ans: B
Feedback:
The nursing diagnosis appropriate for this situation is risk for injury because the firearm
is in the dining room. The parents need instruction about safety precautions with
firearms and school-age children. There is no evidence of anxiety. The parents are not
asking for health-related information. The parents are not demonstrating readiness to
learn more about parenting.
5. When planning activities for school-age children, the nurse includes games that include
competition. At which age are these kinds of games the most preferred by children?
A) 7 years old
B) 8 years old
C) 10 years old
D) 12 years old
Ans: C
Feedback:
During the 10th year, children become very interested in rules and fairness. Before this
time, they gave younger children breaks in games, allowing extra turns or hints. Now,
they strictly enforce rules. At age 7 years, imaginative play decreases and more props
are used. Children who are 8 years old like table games but avoid competitive ones
because they hate to lose. Twelve-year-olds enjoy all types of activities that may or may
not include competition.
6. Why should the nurse carry information about the Boy Scouts when visiting families
with male school-age children?
A) No girls are included in the organization.
B) Hiking is a favorite school-age activity.
C) Merit badges are rewarded for completing small tasks.
D) It strengthens relationships with fathers who participate in Boy Scouts.
Ans: C
Feedback:
Merit badge systems such as the Boy Scouts are geared to the needs of school-age
children, offering small but frequent rewards. This action strengthens the developmental
task of industry. The Boy Scouts is not attractive because the lack of girls, participating
in hiking, or strengthening relationships with fathers.
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7. The nurse knows that being able to tell time helps a child become more independent. At
which age should the nurse expect a school-age child to begin to tell time?
A) 6 years old
B) 7 years old
C) 8 years old
D) 9 years old
Ans: B
Feedback:
Most 7-year-olds can tell the time in hours, but they may have trouble with concepts
such as “half past” and “quarter to,” especially with the prevalence of digital clocks.
Six-year-olds still define objects by use. Eight- and nine-year-olds have moved passed
telling time and are interested in mastering other things.
8. While straightening the top drawer of a 10-year-old patient the nurse finds 48 packets of
sugar. What should the nurse do at this time?
A) Advise the mother to have the child tested for diabetes.
B) Throw out the sugar because this will promote dental caries.
C) Place the sugar packets in the drawer as they were found.
D) Ask the mother if the child has a history of craving sweets.
Ans: C
Feedback:
Ten-year-olds like having their own bedroom or at least their own dresser, where they
can store a collection and know it is free from parents' or siblings' eyes. One of the best
gifts for a 10-year-old is a box which locks. The nurse found the 10-year-old child's
collection and needs to return it where it was found. The child does not have diabetes.
The nurse should not throw out the child's collection. The mother does not need to be
asked about the child's craving sweets.
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9. The nurse is talking with a mother who is concerned that a school-age child is
experiencing stress and has been biting the fingernails since beginning the first grade.
What should the nurse advise the mother to do about this problem?
A) Encourage the child to drink more milk for stronger nails.
B) Allow the child to choose a reward for not biting the nails.
C) Distract the child by teaching a new skill such as whistling.
D) Allow some time every day for the child to talk about new experiences.
Ans: D
Feedback:
Many first-graders are capable of mature action at school but appear less mature when
they return home. They may bite their fingernails. Scolding, nagging, threatening, or
punishing does not stop nail biting and may make the problem worse. This behavior will
stop when the underlying stress is discovered and alleviated. The mother should be
encouraged to spend some time with a child after school or in the evening so the child
continues to feel secured in the family and does not feel pushed out by being sent to
school. Drinking milk will not help alleviate the child's stress. Using rewards or
teaching new skills will not relieve the child's stress.
10. The nurse observes a school-age child categorize specific desk and clothing items in his
hospital room. What cognitive behavior has this child mastered?
A) Decentering
B) Conservation
C) Class inclusion
D) Accommodation
Ans: C
Feedback:
Class inclusion is the ability to understand that objects can belong to more than one
classification. A school-age child can categorize objects in many ways. Decentering is
the ability to project oneself into another person's situation. Accommodation is the
ability to adapt thought processes to fit what is perceived. Conservation is the ability to
appreciate that a change in shape does not mean a change in size.
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11. A mother is concerned that a 7-year-old child has taken money from a sibling's dresser
several times. What should the nurse advise the mother about this behavior?
A) The child needs to be reminded of property rights.
B) Stealing is unusual for a 7-year-old and needs to be investigated.
C) The mother should purchase a bank for the other child that cannot be opened.
D) The mother should talk to the child's teacher about putting less pressure on the
child.
Ans: A
Feedback:
Early childhood stealing is best handled without a great deal of emotion. A parent
should tell the child the money is missing. The importance of property rights should be
reviewed: The sibling's money is his, the child's money is the child's, and they are not
interchangeable. Stealing is not unusual for a 7-year-old child. The mother does not
need to buy the other child a bank. The behavior does not necessarily occur because of
school-related stress.
12. A 9-year-old girl tells the nurse about belonging to a spite club. How does belonging to
this group support the child's development?
A) Fulfills peer group needs
B) Teaches the child leadership skills
C) Helps the child develop autonomy
D) Encourages the child to learn rules
Ans: A
Feedback:
Nine-year-olds take the values of their peer group very seriously. This is typically the
friend or club age because children form groups, usually “spite clubs.” This type of club
does not teach the child leadership skills, develop autonomy, or to learn rules.
13. The mother of a school-age child is distraught because the child has been diagnosed
with obesity. What actions should the nurse suggest to the mother to help the child with
this problem? (Select all that apply.)
A) Explain that obesity will lead to an early death.
B) Maintain a balanced eating approach in the home.
C) Purchase books explaining the latest ways to lose weight.
D) Seek out a preteen weight loss group for the child to participate.
E) Encourage increased activity such as walking the dog after school.
Ans: B, D, E
Feedback:
Strategies to help the school-age child with obesity include maintaining a healthy eating
approach in the home, seeking a weight loss group with other preteens for the child to
attend, and encouraging increased activity. Explaining that obesity will lead to an early
death could cause the child to become obsessed with dieting and create an eating
disorder. The child should not be encouraged to use fad diets to lose weight.
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14. The nurse has been caring for a family with a school-age child who has school phobia.
Which observation indicates that interventions have been successful?
A) The child stays home from school.
B) The child attends school every day.
C) The child decides daily about attending school.
D) The child's teacher is asked if attending school is a requirement.
Ans: B
Feedback:
Once it has been established that a child is free of any illness and the resistance stems
from separation anxiety or phobia, the child should be made to attend school.
Reinforcement by parents to go to school this way helps to prevent problems such as
school failure, peer ridicule, or a pattern of avoiding difficulties. Some children may
benefit from a gradual program of school involvement. Managing school refusal
requires coordination among the school, school nurse, and health care provider who
identifies the problem. The child should not be permitted to decide not to go to school.
Attending school is a requirement, and the teacher does not need to be asked this
question.
15. A 10-year-old child spends 2 hours alone every afternoon before the parents arrive
home from work. Which safety measure should the nurse suggest the parents teach the
child?
A) Preparing a no-cook snack after school
B) Lighting candles in case there is a power failure
C) Wearing the house key prominently around the neck
D) Telling people at school about being home alone or added safety
Ans: A
Feedback:
Parents should plan after-school snacks for the child that does not require cooking to
prevent burns. Lighting candles could be a fire hazard if they are left unattended.
Wearing the house key around the neck could indicate that the child will be home alone.
Telling people at school about being home alone could encourage a break in or other
action against the child.
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16. A mother is concerned that a school-age child will pick up the habit of smoking because
so many children in the school smoke. What should the nurse instruct the mother about
this behavior?
A) Be a role model and do not smoke.
B) Remind the child that smoking costs money.
C) Discuss other tobacco choices that can be used instead.
D) Explain that the child can experiment with smoking when older.
Ans: A
Feedback:
To discourage use of tobacco by school-age children, parents need to be role models of
excellent nonsmoking health behavior in hopes children will follow their good example.
Explaining that smoking costs money might not make an impact on a school-age child's
decision to start smoking. Discussing other tobacco choices is inappropriate because
smokeless tobacco also has associated health risks. The child should be encouraged to
refrain from smoking throughout life.
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Chapter 33 Nursing Care of a Family With an Adolescent
1. An adolescent patient is concerned about the presence of facial acne. What should the
nurse teach the patient about the cause of this skin disorder?
A) Caused by thyroid gland secretions
B) Develops because of poor personal hygiene
C) Caused by the activation of androgen hormones
D) Appears when there is a vitamin deficiency from an inadequate diet
Ans: C
Feedback:
Acne is a self-limiting inflammatory disease that involves the sebaceous glands, which
empty into hair shafts. One cause for the development of acne is an increase in androgen
levels, which cause sebaceous glands to become active. Acne is not caused by thyroid
gland secretions. Acne does not develop because of poor personal hygiene; although,
poor hygiene can make acne worse. Acne is not caused by a vitamin deficiency.
2. An adolescent is prescribed tretinoin (Retin-A cream) as therapy for acne. What should
the nurse instruct the patient about this medication?
A) Avoid unprotected sun exposure.
B) Apply the cream while the face is wet.
C) Avoid using the medication prior to bedtime.
D) Avoid applying the cream directly on lesions.
Ans: A
Feedback:
A common prescription medication for acne is tretinoin (Retin-A cream). This
medication reduces keratin formation and plugging of ducts. Adolescents should be
cautioned to avoid prolonged sun exposure and to use a sunblock of SPF 15 or higher
because the preparation makes their skin more susceptible than usual to ultraviolet rays.
This medication is not typically applied to a wet face. It can be used prior to bedtime. It
should be applied directly to lesions.
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3. The school nurse is preparing an educational session for adolescents to address the 2020
National Health Goals for healthy habits. What should the nurse include in this
presentation? (Select all that apply.)
A) Abstaining from alcohol
B) Avoidance of tobacco products
C) Maintaining a healthy body weight
D) Attending college preparation programs
E) Refusing to participate in substance abuse
Ans: A, B, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for adolescent
healthy habits by educating adolescents about the use of cigarettes, smokeless tobacco,
alcohol, and substance abuse, and reducing the number of adolescents who are obese.
College preparation programs will not necessarily help adolescents achieve healthy
habits.
4. During a physical assessment, a 15-year-old male expresses concern about being short
in height. Which should the nurse respond to this patient's concern?
A) Most male adolescents stop growing by age 17 years.
B) Maximum height is typically achieved by age 14 years.
C) The epiphyseal lines of long bones close when signs of puberty occur.
D) The epiphyseal lines of long bones close at about 18 to 20 years of age in males.
Ans: D
Feedback:
Growth stops with closure of the epiphyseal lines of long bones, which occurs at about
18 to 20 years of age in males. Most adolescent males do not stop growing by age 17
years. Maximum height is not achieved by age 14 years. The epiphyseal lines of long
bones do not close when signs of puberty occur.
5. The nurse is preparing to discuss the most frequent causes of death in adolescents with a
group of high school students. On which area should the nurse focus during this
discussion?
A) Water safety
B) Home safety
C) Firearm safety
D) Motor vehicle safety
Ans: D
Feedback:
Unintentional injuries, most commonly those involving motor vehicles, are the leading
cause of death among adolescents. This is the area in which the nurse should focus
during the discussion with the high school students. Water, home, and firearm safety are
not identified as leading causes of death in adolescents.
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6. The nurse is caring for a 17-year-old patient recovering from a failed suicide attempt.
Which factor should the nurse recognize as potentially causing the patient to reattempt
suicide?
A) Patient states feeling sad.
B) Patient has three other siblings.
C) Patient performs in the school band.
D) Patient is on the honor roll at school.
Ans: A
Feedback:
Some degree of depression is present in most adolescents because they are not only
losing their parents at this time as they grow apart from them but they are also losing
their carefree childhood. Feeling sad is an indication of depression. Having siblings,
performing in the school band, and being on the honor roll are not identified as factors
for the patient to reattempt suicide.
7. The nurse is identifying outcomes for an adolescent patient who has been avoiding
bread products and grains in order to lose weight. Which outcome should the nurse
identify as appropriate for this patient's nutritional needs?
A) Patient will ingest bread and grain products during breakfast.
B) Patient will have no further signs of calcium, iron, and zinc deficiency.
C) Patient will have no further signs of thiamine and riboflavin deficiency.
D) Patient will ingest bread and grain products when eating out with high school
friends.
Ans: C
Feedback:
Many adolescents omit breads and cereals entirely to lose weight rather than just
reducing the amounts they eat. Diets such as these can be deficient in thiamine and
riboflavin, vitamins necessary for growth. The outcome in which the adolescent is
without signs of thiamine and riboflavin deficiency would be appropriate for this
patient. The outcome where the patient ingests bread and grains with breakfast might
not be sufficient for the adolescent's growth needs. The outcome that focuses on
calcium, iron, and zinc deficiency would be appropriate if the adolescent avoids eating
meat, milk products, and green vegetables. The outcome where the patient ingests bread
and grain products with high school friends might not be a sufficient amount to meet the
growing adolescent's health needs.
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8. The nurse is caring for a 16-year-old adolescent who was arrested for driving while
intoxicated. Which teaching method will be most effective in getting the patient to
discontinue alcohol use?
A) Scolding the patient for such irresponsible behavior
B) Reviewing the long-term effects of alcohol on the liver
C) Teaching that alcohol eventually will lead to other drug abuse
D) Stressing that the driver's license can be lost if drinking continues
Ans: D
Feedback:
Adolescents are very present oriented, so a program such as losing the driver's license
provides immediate results and will usually be carried out well. In contrast, a regimen
oriented toward the future, with long-term goals such as effects of alcohol on the liver or
leading to other drug use may not be as successful. Scolding is not a teaching method.
9. An adolescent admits to using marijuana on a daily basis. What should the nurse explain
to the patient to help improve performance in school?
A) The effect of marijuana fades fastest if eating occurs after use.
B) Marijuana causes memory gaps that interfere with learning.
C) Marijuana leads to muscle laxness, so it should not be used close to gym class.
D) Marijuana increases blood pressure; running should not be done after smoking it.
Ans: B
Feedback:
The products of marijuana are not readily eliminated from the body but remain in the
fatty cells of the brain. This residue can create synaptic gaps that interfere with electrical
brain waves and memory storage, especially for short-term memory. This will affect
learning. The effects of marijuana do not fade faster if eating occurs after use. Marijuana
use is not linked to physical performance or blood pressure.
10. The nurse is caring for an adolescent who has been diagnosed with obesity. Which
nursing diagnosis would the best for the nurse to use when planning this patient's care?
A) Risk for low self-esteem
B) Ineffective individual coping by overeating
C) Anxiety related to concerns about normal growth and development
D) Health-seeking behaviors related to normal growth and development
Ans: B
Feedback:
The nursing diagnosis most appropriate for an adolescent with obesity is ineffective
individual coping by overeating. The risk for low self-esteem could be due to acne or
other physical body changes in adolescence. The patient may or may not have anxiety
related to normal growth and development. The patient is not demonstrating
health-seeking behaviors.
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11. The nurse is caring for an adolescent who is physically challenged. Which activity
should the nurse suggest that will foster the developmental task of adolescence?
A) Watching television
B) Deciding when to have a bath
C) Having a teacher bring school homework to the hospital
D) Talking to another adolescent who has a similar disorder
Ans: D
Feedback:
According to Erikson, the developmental task in early and mid-adolescence is to form a
sense of identity versus role confusion. Main areas in which an adolescent must make
gains to achieve a sense of identity include accepting a changed body image. Talking to
another adolescent with the same disorder will help the patient achieve the
developmental task of identity. Watching television, deciding when to take a bath, or
having schoolwork provided while hospitalized does not support the developmental task
of adolescence.
12. The nurse instructs an adolescent on the hazards of body piercings and tattoos. Which
outcome indicates that teaching has been effective?
A) The patient gets a small tattoo on the inner ankle.
B) The patient refuses to get eyebrow pierced with girlfriends.
C) The patient observes a tattoo being done and decides to get one with an older
brother.
D) The patient limits body piercings and tattoos to areas on the trunk.
Ans: B
Feedback:
Evidence that teaching about body piercings and tattoos has been effective is the patient
refuses to get eyebrow pierced with girlfriends. Getting any type of tattoo or body
piercing on a body location indicates that teaching has not been effective.
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13. An adolescent comes into the emergency department with a foot wound. Upon
assessment, the nurse learns that the patient is a runaway and has been living on the
streets. Which is the most appropriate care for the nurse to provide to the patient at this
time?
A) Recommend returning to live with parents.
B) Treat the wound and provide wound care supplies.
C) Discuss the importance of a diet high in protein and vitamin C.
D) Explain how the wound needs to be flushed with water every 4 hours.
Ans: B
Feedback:
The nurse is not aware of the adolescent runaway's family situation so suggesting
returning home with parents may or may not be appropriate. Because the adolescent
runaway has no money for any kind of food, giving instructions to eat foods high in
protein and vitamin C makes no sense. If the adolescent runaway does not have a source
of running water, telling them to flush the wound with water every 4 hours will be
impossible. The best care at this time would be for the nurse to treat the adolescent
runaway's wound and provide with wound care supplies.
14. During a routine health checkup, an adolescent patient expresses concern about being
sexually active at such a young age. What can the nurse instruct the patient with sexual
issues? (Select all that apply.)
A) Do not be influenced by friends to have sex.
B) There is no 100% method to prevent pregnancy.
C) Learn about and practice safe sexual techniques.
D) Sexual activity does not harm routine physical activity.
E) Adolescence is the time when all sexual activity begins.
Ans: A, B, C, D
Feedback:
Health teaching guidelines for adolescents regarding sexual activity include not being
influenced by friends regarding sex, knowing that there is no 100% method to prevent
pregnancy, learning about and practicing safe sexual techniques, and sexual activity
does not harm physical strength or general wellness. Adolescence is not the time when
all sexual activity begins. Sexual activity is an individual activity that is based on level
of maturity.
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15. The nurse is caring for a chronically ill adolescent patient. What can the nurse do to
maintain stimulation and support the patient's sense of identity while hospitalized?
A) Plan activities around scheduled rest periods.
B) Explain food choices appropriate to the prescribed diet.
C) Teach the name and indications for use of all medications.
D) Encourage communicating with friends through social media.
Ans: D
Feedback:
To encourage stimulation while supporting the adolescent patient's sense of identity
while hospitalized, the nurse should encourage the patient to communicate with friends
through social media. Planning activities around rest periods does not promote
stimulation. Explaining food choices does not promote stimulation. Learning about
medications does not promote stimulation.
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Chapter 34 Child Health Assessment
1. The nurse is beginning a health history with a 3-year-old child. Which question should
the nurse ask the mother first when beginning the history?
A) “Is Sarah ill in any way?”
B) “Tell me about your daughter.”
C) “Has Sarah been ill in the past?”
D) “Do you have any concerns about Sarah?”
Ans: D
Feedback:
The most appropriate question to begin a health history is open ended. This type of
question allows the parent to elaborate on the health of the child. Close-ended questions
such as asking if the child has been ill or if the child has been ill in the past limit the
amount of information learned for the history. Expansive statements such as “tell me
about your daughter” are too vague.
2. The nurse is identifying ways to support the 2020 National Health Goals during the
upcoming preschool health screening program. What should the nurse include when
conducting the program? (Select all that apply.)
A) Conduct vision tests.
B) Conduct hearing tests.
C) Listen to heart sounds.
D) Measure gait and balance.
E) Review immunizations received.
Ans: A, B, E
Feedback:
To support the 2020 National Health Goals related to health assessment of children, the
nurse should participate actively in health assessment, including vision and hearing, and
screening for and administering vaccines. Listening to heart sounds and measuring gait
and balance do not support the 2020 National Health Goals related to health assessment
of children.
3. The nurse wants to find out how much time a preschooler spends in various activities
throughout the day. What should the nurse do to learn this information?
A) Ask the parents to complete a day history.
B) Ask the parents to name the games the child knows.
C) Ask the child how much time the mother is with the child.
D) Ask the parents how many hours is spent playing with the child each day.
Ans: A
Feedback:
The child's current skills, sleep patterns, hygiene practices, eating habits, and
interactions with the family can all be elicited by asking a parent to describe a typical
day. Day histories are fun to obtain because most parents are eager to describe their day
with their child, and information gained this way is surprisingly rich and pertinent,
much more so than if parents are just asked how their child sleeps, eats, or plays.
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4. The nurse is preparing to measure the head circumference of a 6-month-old child. How
should the nurse make this measurement?
A) From the hairline in front to the hairline in back
B) From the center of the forehead to the base of the occiput
C) Above the eyebrows through the prominent part of the occiput
D) From the middle of the forehead through the parietal prominences
Ans: C
Feedback:
Head circumference is measured by placing a tape measure around an infant's head just
above the eyebrows and around the most prominent portion of the back of the head or
the occipital prominence. Head circumference is not measured using the hairline or the
forehead.
5. The nurse is preparing to assess the abdomen of a preschool age child. Which technique
should the nurse use first?
A) Palpation
B) Inspection
C) Percussion
D) Auscultation
Ans: B
Feedback:
To assess an abdomen, first inspect the surface for symmetry and contour. After
inspection, the nurse should auscultate for bowel sounds. The examination concludes
with percussion and palpation.
6. The nurse is listening to the breath sounds of a 4-year-old child. Which sound should the
nurse determine as being normal for this patient?
A) Stridor
B) Crackles
C) Rhonchi
D) Wheezing
Ans: C
Feedback:
Rhonchi are snoring sounds that are made by air moving through mucus in the bronchi.
This is a normal sound. Stridor is a crowing sound being made through a constricted
larynx. This is an abnormal sound. Crackles are sounds made by air moving through
fluid. This is an abnormal sound. Wheezing is a whistling sound made by air moving
through a narrow bronchus. This is an abnormal sound.
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7. The nurse is preparing care for a preschool-age child scheduled for a health history and
physical assessment. At which point will the nurse determine nursing diagnosis
appropriate for the child's care?
A) Prior to the assessment
B) At the time of assessment
C) After completing the review of systems
D) After specific problems have been identified
Ans: B
Feedback:
Nursing diagnosis related to health assessment most commonly address a health concern
identified at the time of the assessment. When establishing nursing diagnoses, do not
overlook diagnoses that accentuate the healthy functioning of a child and family, even
when diagnoses that address specific problems have been identified. Wellness diagnoses
are crucial components of the entire assessment picture. The nurse cannot identify
diagnoses before the assessment occurs.
8. The nurse is preparing to conduct a physical examination of a 3-year-old child. Which
assessment will the nurse introduce for the first time to this patient?
A) Snellen vision testing
B) Blood pressure recording
C) Observation of walking gait
D) Standing height measurement
Ans: B
Feedback:
Blood pressure measurement begins to be a part of routine assessment at 3 years of age.
The preschool E-chart is used for vision screening at this age. Walking gait and standing
height measurement will be introduced in future assessments.
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9. During a previous well-child visit, the nurse reviews the importance of immunizations
for the preschool-age child with the parents. Which outcome indicates that the nurse's
instruction to the parents has been effective?
A) Child has all immunizations up to date.
B) Parents plan to have the child receive needed immunizations within a year.
C) Child began to cry during an immunization, and the decision was made to try
again later.
D) Primary care physician changed the appointment for immunizations to another
day in a month.
Ans: A
Feedback:
One of the most important health assessment and promotion measures for children is to
establish their immunization status is up to date. The nurse should teach parents about
the importance of having their children immunized and the need to be able to describe
the record of immunizations a child has received. If gaps are present in a child's number
of immunizations, remind the child's primary care provider about this lack in protection
and prepare to administer the necessary vaccines. The child's immunizations begin up to
date indicate that the nurse's instruction has been effective. Having the child immunize
within a year might expose the child to pathogens than could be avoided. Children will
cry when receiving injections. This is not a valid reason to postpone immunization. The
health care provider needs to understand the importance of childhood immunizations to
be received at the correct age and time.
10. The nurse is preparing to conduct the cover test with a preschool-age child. Which body
system is the nurse preparing to assess?
A) Ears
B) Eyes
C) Nose
D) Neck
Ans: B
Feedback:
A screening procedure to determine eye alignment is the cover test. The cover test is not
used to assess the ears, nose, or neck.
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11. The nurse is preparing to administer the Denver II Developmental Screening Test to a
preschool-age child. Which areas of the child's development should the nurse explain to
the mother that this test measures? (Select all that apply.)
A) Social
B) Language
C) Fine motor
D) Intelligence
E) Gross motor skills
Ans: A, B, C, E
Feedback:
The Denver II Developmental Screening Test is the most widely used tool to assess
early childhood development and rates the categories of personal–social, fine
motor–adaptive, language, and gross motor skills. The nurse should explain to the
parent before administering the test that this test does not measure intelligence but of the
child's level of development or ability to perform age-appropriate tasks.
12. When conducting the Rinne test for hearing with a school-age child, the nurse learns
that the child is unable to hear the sound when the tuning fork is moved to the auditory
meatus. What does this finding suggest to the nurse?
A) The child is totally deaf.
B) The child has normal hearing.
C) The child has minimal air conduction for hearing.
D) The child has minimal bone conduction for hearing.
Ans: C
Feedback:
The Rinne test is conducted by placing the stem of a tuning fork against the mastoid
bone. When the sound disappears the fork is then moved to the auditory meatus. If the
sound cannot be heard at the auditory meatus, this means air conduction of sound is
impaired. This does not mean that bone conduction of sound is impaired. This does not
mean that the child has normal hearing. This also does not mean that the child is totally
deaf.
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13. The nurse is preparing to assess a school-age child who is experiencing pain in the left
femur area. When conducting this assessment, at which point should the nurse assess the
painful region?
A) Last
B) First
C) After measuring vital signs
D) Before the abdominal assessment
Ans: A
Feedback:
If a child has a sensitive or painful body part, palpate that area last. Otherwise, the child
may be unwilling to allow other parts to be touched in fear of additional pain. The
painful regions should not be assessed first, after measuring vital signs, or before the
abdominal assessment.
14. When beginning a physical examination of a toddler, the nurse notes that the child has
halitosis. On which body areas should the nurse focus when conducting the assessment?
(Select all that apply.)
A) Lungs
B) Urinary
C) Reflexes
D) Abdomen
E) Oral cavity
Ans: A, E
Feedback:
Halitosis or bad breath is considered a significant body odor, which could be caused by
poor dental hygiene, a lung infection, or a foreign body in respiratory tract. The nurse
should focus the assessment on the lungs and the oral cavity. The urinary tract, reflexes,
and abdomen will not help determine the cause for the patient's halitosis.
15. The nurse is planning an education session for adolescent males on health promotion
activities. Which topic should the nurse include as being the most applicable for this
population?
A) Reproductive cycle
B) Immunization schedule
C) Importance of socialization
D) Testicular self-examination
Ans: D
Feedback:
Starting in adolescence, all males need to perform testicular self-examination once a
month. This is the health promotion activity in which the nurse should focus for this
educational session. The reproductive cycle might be more appropriate for adolescent
females. Immunization schedule and socialization would be more appropriate for
younger children and parents.
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Chapter 35 Communication and Teaching With Children and Families
1. The nurse is planning activities to support the 2020 National Health Goals that address
health teaching. Which action should the nurse take to ensure these goals are supported?
A) Develop a teaching plan for a school-age child.
B) Examine available teaching materials to use when conducting training sessions.
C) Work with a school district to develop appropriate health teaching for the
students.
D) Assess the learning leads of parents of a preschool-age child with type 1 diabetes
mellitus.
Ans: C
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals by consulting with
schools and health care organizations to develop what health teaching programs are
needed and then teaching in such programs. Developing a teaching plan for a child,
examining teaching materials, and assessing learning needs of parents will not necessary
help achieve the 2020 National Health Goals.
2. The nurse is preparing to teach a school-age child how to apply gauze wrap to a leg
dressing. Which approach is the best for the nurse to use with this patient?
A) Talk about the procedure.
B) Demonstrate the procedure.
C) Show pictures of the procedure.
D) Review the written steps of the procedure.
Ans: B
Feedback:
Because of their stage of cognitive development, which is concrete operations,
school-age children learn best by demonstration. The nurse needs to do more than talk
about the procedure. Showing pictures of the procedure is not enough with this age
group. Reviewing the written steps of the procedure is too advanced for this age group.
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3. The nurse provided a preschool-age child with instructions prior to having a surgical
procedure. The parents of the child were in attendance, and the child was alert and
participated in the education session. During postoperative care, the child is unable to
recall anything that was instructed. What does this finding suggest to the nurse about the
communication process?
A) The code was not received.
B) The feedback was not truthful.
C) The decoder did not receive the message.
D) The encoder failed to communicate the message.
Ans: C
Feedback:
There are several parts to the communication process. The encoder is the person
delivering the message. The nurse was the encoder who provided teaching to the child.
The code is the message being delivered. This was the teaching for the surgical
procedure. Because the child was alert and participated in the education, it appears that
the code was received. The decoder is the child. Because the child was unable to recall
any of the teaching, it could be because of stress. Under stress, children tend to narrow
their ability to receive information to a small area of concern. Children, who are
extremely anxious, may not “hear” or be unable to interpret the message because of
anxiety, even though excellent instructions were provided. Feedback is the reply the
decoder returns to the sender to acknowledge the message has been received and
interpreted. Because the child was alert and participated in the education, it is unlikely
that the feedback was not truthful.
4. A school-age child is newly diagnosed with type 1 diabetes mellitus. Which behavior
indicates to the nurse that the child might be interested in learning how to
self-administer insulin injections?
A) The child cries and calls for the mother with every insulin injection.
B) The child watches the nurse fill and asks to hold the insulin syringe.
C) The child asks how many “shots” are needed before the illness is “all better.”
D) The child tells the nurse that a parent will give the injection so the parent needs
the teaching.
Ans: B
Feedback:
Designing a teaching plan begins with assessment of the individual child's needs and
how the new knowledge will meld with the child's and family's lifestyle, the child's
intellectual and language level, current knowledge level, physical/cognitive capabilities,
sociocultural values, and attention span. Because the child is school-age and is a
concrete thinker, the child who watches the nurse fill and asks to hold the syringe is the
most ready for teaching about self-administration of insulin injections. The child who
cries for the mother is not emotionally mature for this teaching. The child who asks how
many “shots” are needed before the illness is “all better” is not intellectually prepared
for this teaching. The child who expects the parent to provide the medication is also not
intellectually prepared for this teaching.
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5. The mother of a child newly diagnosed with muscular dystrophy appears overwhelmed
the care the child will need once discharge occurs. Which nursing diagnosis is the most
appropriate for the nurse to select to help guide this mother's learning needs?
A) Health-seeking behaviors related to ways to care for the child at home
B) Effective coping related to understanding the home care needs of the child
C) Deficient knowledge related to type and amount of care needed for the child
D) Anxiety related to perceived amount of material needed to be learned for home
care of child
Ans: D
Feedback:
The mother appears overwhelmed, which would indicate anxiety related to the amount
of learning needed to care for the child at home. This is the diagnosis that the nurse
should use to guide the mother's learning needs. The mother is not asking questions
about the care so health-seeking behavior is not appropriate at this time. The mother
appears overwhelmed so effective coping is not appropriate at this time. The nurse has
not assessed the mother so deficient knowledge is not appropriate at this time.
6. The nurse is implementing the teaching technique of behavior modification for a
cognitively challenged child. Which nursing action should the nurse use when
implementing this technique?
A) Giving the child a sticker for sitting still for 10 minutes
B) Taking away television-watching privileges for running
C) Giving the child an extra chore to do for talking in class
D) Not allowing the child to play outside for rude behavior
Ans: A
Feedback:
Learning occurs best with positive reinforcement. Behavior modification is a term used
for a system aimed at erasing some form of behavior that interferes with healthy
functioning. The basic premise of behavior modification is that a child is rewarded for
healthful behavior, whereas unhealthful behavior is ignored or unrewarded. The
preferred behavior is praised, and the unacceptable behavior is ignored. Children
respond best to behavior modification if they receive a tangible reward such as a sticker
for good behavior. Taking away television, giving extra chores, and not permitting
outdoor play are negative behaviors and do not support behavior modification.
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7. The nurse is preparing to teach a 9-year-old how to do active range-of-motion exercises.
Which technique is the most appropriate for the nurse to use for this teaching?
A) Allow the child to listen to the radio during instruction.
B) Demonstrate the technique by performing it consistently the same each time.
C) Suggest the child he or she tell you how the range-of-motion exercises are to be
done.
D) Tell the child different ways to perform the technique so that they can be varied.
Ans: B
Feedback:
Being told different ways to perform a new skill is confusing. The nurse should select
the technique and perform it consistently each time. The child is not going to learn the
technique if listening to the radio during teaching. The child is not aware of the
technique and will not know how to perform the exercises. After a child has learned the
one method, alternative methods can be suggested if the child is interested.
8. After teaching a school-age child how to apply a gauze wrap to a lower extremity,
which observation indicates that teaching has been successful?
A) The child shows an eagerness to learn more things.
B) The child returns an adequate demonstration of wrapping the limb.
C) The child consistently wraps the lower extremity as instructed each time.
D) The child explains the importance of wrapping the lower extremity with gauze.
Ans: C
Feedback:
Demonstration of a change of behavior is the real proof learning has occurred. The child
consistently wrapping the lower extremity as instructed is evidence that learning has
been successful. An eagerness to learn does not demonstrate that teaching about the
gauze wrap has been successful. Returning an adequate demonstration on wrapping the
limb does not mean that the child will consistently perform this action every time.
Explaining the importance of wrapping the lower extremity with gauze does not indicate
that teaching has been successful.
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9. A school-age child was instructed on transfer techniques after having spinal surgery. For
which outcome should the nurse assess when making a home visit to this patient?
A) Patient transfers from bed to a chair unassisted.
B) Patient stands up and walks to a chair with parental assistance.
C) Patient transfers from the bed to a chair with one person assisting.
D) Patient unable to move from the bed to a chair without assistance.
Ans: A
Feedback:
An outcome is the focus or goal of the instruction. For the child being instructed on
transfer techniques after spinal surgery, the nurse should assess for the child's ability to
perform the transfer as instructed, or the patient is able to transfer from the bed to a
chair unassisted. The patient standing up and walking is evidence that instruction was
not effective. The need to have one or more people assisting with the transfer indicates
that instruction was not effective and the outcome was not met.
10. Which technique should the nurse use to teach an adolescent about a newly diagnosed
disease process?
A) Urge the adolescent to listen attentively during teaching.
B) Help the adolescent understand how this information will improve future health.
C) Help the adolescent realize that teaching is needed above what peers need to learn.
D) Help the adolescent understand how this information will improve health status
now.
Ans: D
Feedback:
Adolescents are very present oriented, and they learn procedures and new information
best if they can see how it will immediately benefit them. They learn poorly if the only
benefit of new information presented to them is something that will affect them at some
future date. Adolescents do not like to be reminded to pay attention. They have a strong
need to be exactly like their friends, which means adolescents rarely continue any action
that makes them different or conspicuous in front of their peers.
11. Which teaching approach should the nurse use to teach a toddler about coughing and
deep breathing?
A) Showing a videotape
B) Demonstrating the technique
C) Discussing the importance of coughing
D) Playing a game with coughing and breathing
Ans: D
Feedback:
Teaching an activity such as deep breathing by having the child imitate the action is an
effective teaching method because it presents the activity as a game. Videotapes,
demonstration, and discussion are not effective teaching strategies with this age group.
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12. While teaching a preschool-age child how to do postoperative exercises, the nurse
recalls that the child will “center” on information. What impact does this have on the
child's learning?
A) The child will learn only the middle part of a procedure.
B) The child will not retain information longer than a week.
C) The child will need printed material to understand the teaching.
D) The child will concentrate on one part of a procedure and appear not to hear
another.
Ans: D
Feedback:
Preschool children “center” or notice only one characteristic of an object. This can limit
their ability to learn all aspects of care or more than one method of doing something on
any one day. This does not mean that the child will only learn the middle of the
procedure. This does not mean that information will not be retained for longer than a
week. This also does not mean that the child will need printed material to understand the
teaching.
13. The nurse is caring for a school-age child who does not speak English. During the night,
a procedure needs to be done and an interpreter is not available. What should the nurse
do to teach the patient about this procedure?
A) Tell the parents to tell the child what will be happening.
B) Draw a picture of the procedure using an anatomically correct figure.
C) Call the interpreter on the phone to explain the procedure to the child.
D) A child of this age does not require a detailed explanation, just perform the
procedure.
Ans: B
Feedback:
If instructions are to be provided to a child who does not understand English, and an
interpreter is not present, the nurse can use draw a picture to explain the procedure. The
nurse does not need to involve the parents in this teaching need. The interpreter is
unavailable. It is not known if the interpreter can be reached by telephone. School-age
children need to be instructed prior to performing any procedure.
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14. The nurse is preparing to teach a 9-year-old patient with asthma about triggers related to
the disease. Which approach should the nurse use for this teaching?
A) Play an allergy trivia game with the patient.
B) Show the patient a video about allergic reactions.
C) Have the doctor teach the patient this information.
D) Give the patient a list of foods that must be avoided.
Ans: A
Feedback:
School-age children enjoy short projects that offer an immediate reward and learn best if
a procedure is broken down into different stages and presented as separate short steps.
They enjoy games, so playing an allergy trivia game would be the best way for the nurse
to teach the patient about asthma triggers. Videos are not an appropriate method to teach
the school-age child. The nurse can teach this information; the physician does not need
to be consulted. The nurse needs to do more than giving the patient a list of food items
to avoid.
15. The nurse is planning to incorporate teaching while caring for a preschool-age child.
Which statement would be appropriate for the nurse to use when caring and teaching
this patient?
A) “Your pulse is 88.”
B) “I need to put a needle in your arm.”
C) “You have to try to eat all of your dinner.”
D) “It's important to put a pillow under your leg so the swelling will go down.”
Ans: D
Feedback:
The nurse should explain the purpose and principles for a procedure. Explaining the
need to place a pillow under the leg so that swelling will go down is how the nurse
should incorporate teaching while providing patient care. The nurse should explain that
a pulse of 88 is normal. The nurse should explain why a needle must be placed in the
child's arm. The nurse should explain why the child needs to eat all of the dinner.
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Chapter 36 Nursing Care of a Family With an Ill Child
1. The nurse is discussing a pending hospitalization of an 8-month-old infant with the
parents. What should the nurse encourage the parents to do when preparing the child for
this hospitalization?
A) Pack her favorite toy.
B) Buy a new pair of soft pajamas.
C) Read her a story on hospitalization.
D) Let her watch her suitcase being packed.
Ans: A
Feedback:
Because an infant cannot understand explanations of surgery or treatments, oral
preparation is minimal. Remind parents to pack special items such as a favorite toy
because this object provides a special kind of security for which there is no substitute.
The infant is not old enough to appreciate a new pair of pajamas. Reading a story will
have no meaning to the child. The child will not understand a suitcase being packed.
2. The mother of an infant is unable to visit the child in the hospital for 3 days. At first, the
baby cries relentlessly but then becomes quiet and withdrawn. What reaction does the
nurse identify as occurring with this child?
A) The infant is fatigued.
B) The infant is developing a sense of denial.
C) The infant is confused about being hospitalized.
D) The infant is ill, which is causing the change in behavior.
Ans: B
Feedback:
In separation anxiety, the stage of protest is when the child cries loudly and is unable to
be comforted. In denial, the child is silent with an expressionless face. The infant's
behavior is not because of fatigue, confusion, or the illness.
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3. The nurses on a pediatric unit are planning an open house for parents and children to
visit the unit in an attempt to reduce the stress when hospitalized. In order to support the
2020 National Health Goals regarding childhood hospitalization and stress, what type of
materials should the nurses prepare for the families?
A) Location of the hospital cafeteria
B) Best places to park when visiting the hospital
C) Checklist of preventive services needed by children
D) Suggested times during the day to visit when the child is hospitalized
Ans: C
Feedback:
Hospitalization is a stressful event to children. There are specific 2020 National Health
Goals to address stress in hospitalized children. Nurses can help the nation achieve these
goals by helping reduce the stress of hospitalization or health care and hospitalization so
families use preventive services to help children stay well rather than totally use
emergent or ill child care services. The nurses should provide a checklist of preventive
services needed by children to prevent hospitalizations. Location of the cafeteria, where
to park, and visiting hours will not reduce the stress of hospitalized children.
4. The nurse is assessing a preschool-age child who is being hospitalized for the first time
for a surgical procedure. The child expresses the desire to go home and is scared. Which
nursing diagnosis should the nurse identify as appropriate for the child at this time?
A) Anxiety related to pending hospital admission
B) Risk for social isolation related to hospitalization
C) Fear related to being away from home for first time
D) Health-seeking behaviors related to lack of knowledge regarding illness
Ans: C
Feedback:
The child is scared about being hospitalized for the first time. The most appropriate
nursing diagnosis would be fear related to being away from home for the first time. The
child is being admitted, so anxiety related to pending hospitalization would not be
appropriate. There is no enough information to support the child being at risk for social
isolation. The child is not asking for information about the illness so the diagnosis
regarding health-seeking behavior is not applicable at this time.
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5. The mother of an infant is upset to learn that the baby's diarrhea caused the infant to
become quite ill. What should the nurse explain about an infant that makes diarrhea an
important problem to treat?
A) Infants have shorter intestines than adults.
B) Infants have a high proportion of extracellular fluid.
C) Infants have a higher proportion of fluid than an adult.
D) Infants have a fluid content that is proportionally less than that of an adult.
Ans: B
Feedback:
In the adult, extracellular water represents approximately 23% of total body water; in a
newborn, extracellular water is closer to 40%. This means that an infant does not have
as much water stored in the cells as an adult and so is more likely to lose a devastating
amount of body water with diarrhea. Because of this, there is no such thing as “only
diarrhea” in a child younger than 1 year of age. Infants do not have shorter intestines
than adults. Infants do not have a higher proportion of fluid than adults. Infants do not
have a fluid content that is proportionally less than that of an adult.
6. The nurse is caring for a 4-year-old confined to bed. Which play experience should the
nurse use as being the most age appropriate for the patient?
A) Helping the patient learn to write
B) Teaching the patient to play checkers
C) Encouraging watching unlimited television
D) Supplying a tray of dry oatmeal for “sand” play
Ans: D
Feedback:
Age-appropriate play for a preschool-age child using materials available to the nurse
includes pouring breakfast cereal into a basin so the child can dig, similar to playing in
sand. Learning to write may not be fun for the child. Checkers is more appropriate for a
school-age child. Preschool-age children might get bored with watching television. They
need an activity in which they participate.
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7. A school-age child who is in the playroom is prescribed to receive an injection. What
should the nurse do when preparing to administer this medication to the child?
A) Inject it in the playroom.
B) Ask to see the patient outside the playroom for the injection.
C) Ask the patient if the injection can be given in the playroom.
D) Ask the other children if they would mind if you give the injection in the
playroom.
Ans: B
Feedback:
The best children's hospital units are equipped with a playroom or play space that is
maintained as a “pain-free” zone. No medical procedures, not even painless ones,
should be performed in this area. The nurse should not provide the injection in the
playroom. Asking the child and other children if the injection can be given in the
playroom violates the “pain-free” zone.
8. Which items should the nurse select as the best to support therapeutic play for a child
who receives daily injections of medication?
A) A doll with a cast in place
B) A syringe to practice injections
C) A stuffed bear with Band-Aids
D) An anatomically correct puppet
Ans: B
Feedback:
The nurse should provide the child with equipment that has been used with them. The
child may poke at a doll with a syringe without a needle or with a small rubber tube
attached to simulate a needle or enjoy giving it a “shot” since this is the child's
experience. The child does not have a cast and does not have bandages. An anatomically
correct puppet is not necessary for the child who receives daily injections.
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9. The nurse is completing the teaching for parents of a toddler recovering from a fracture.
Which outcome should the nurse identify to help determine if teaching has been
effective?
A) The child resumes normal activity level at home.
B) The parents encourage the child to be independent.
C) The parents place a locked gate at the top of the stairs.
D) The child waits for the parent to assist before walking down a set of stairs.
Ans: D
Feedback:
Promoting safety for children is a responsibility for all health care providers. Care of a
child who is ill or one with a unique concern at home includes assessing the safety of
the house and providing family teaching. The expected outcome after teaching would be
that the child waits for the parent to assist before walking down a set of stairs. The child
is a toddler with a fracture. The child will not be able to resume normal activity level at
home. The child is too young to be independent. Locking a gate could be a safety
hazard. The child may decide to climb over the gate and fall down the stairs.
10. The nurse is planning care for a school-age child being admitted to the hospital for a
chronic illness. Which hazards of hospitalization for children will the nurse use to plan
this patient's care? (Select all that apply.)
A) Meeting new people
B) Unsure of acceptable behavior
C) Losing control over the environment
D) Experiencing physical discomfort and pain
E) Being separated from family, school, and friends
Ans: B, C, D, E
Feedback:
Hazards that may occur with children with an illness includes unclear definition of
acceptable and expected behavior; losing control over the ability to make decisions;
experiencing physical discomfort and pain; and being separated from routines, parents,
and peers. Meeting new people is not a hazard for child hospitalized with an illness.
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11. The nurse is helping the parents explain to a toddler the need to go to the hospital for a
tonsillectomy. When explaining the procedure to the child, which phrase should the
nurse and parents avoid using?
A) “You will be able to eat popsicles.”
B) “Your mommy and daddy will be with you.”
C) “The bad tissue will be cut out of your throat.”
D) “You will get medicine so that you feel better.”
Ans: C
Feedback:
One chief fear of toddlers is the fear of mutilation. It is always better to use the word
“fix” rather than “cut” when talking about surgery with young children, because “cut”
automatically suggests pain and mutilation. Saying that bad tissue will be cut out of the
throat can conjure up a horrific scene for a toddler and should not be used. Eating
popsicles, having the parents with the child, and getting medicine to feel better are
appropriate phrases to use when discussing surgery with a toddler.
12. A preschool-age child is being admitted to the hospital for treatment of cellulitis. The
child's parents appear upset and frightened. Which question should the nurse use to
elicit information concerning the parents' understanding of why the child is being
admitted to the hospital?
A) “Are you worried? I'll tell you everything you need to know.”
B) “Why are you so concerned? We take good care of children here.”
C) “Has the doctor told you why your daughter requires hospitalization?”
D) “You seem concerned; do you have questions about your child's admission?”
Ans: D
Feedback:
When admitting a child to the hospital, the nurse should determine what the parents'
understanding is of why the child is being admitted. This could be best assessed by
asking if the parents have any questions about the child's admission. The nurse may or
may not be able to tell the parents everything they need to know. Minimizing the
parent's concerns is an inappropriate response. The parent's understanding of why the
child is in the hospital may be different than what the physician may have said or
believes.
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13. While hospitalized, a school-age child began sleepwalking. The nurse teaches the
parents how to handle sleepwalking once the child is discharged. Which statement
indicates that this teaching has been effective?
A) “We should not wake up the child.”
B) “We should shake the child to wake up immediately.”
C) “We should wake the child up gently and return the child to bed.”
D) “We should keep the child awake in the living room to play before going to bed.”
Ans: C
Feedback:
It is untrue that sleepwalkers should not be wakened. The child should be woken gently,
be reoriented, and then returned to bed after reassurance of being safe. The child can be
woken up. The child should not be shaken. The child should not be encouraged to play
before going back to bed.
14. The nurse is planning to meet the spiritual needs of a 6-year-old child who is
hospitalized. Which child behavior should the nurse encourage to provide security to the
child who is in a strange environment?
A) Saying bedtime prayers
B) Hanging a religious picture over the bed
C) Giving the child a Bible to keep at the bedside
D) Asking the hospital chaplain to visit with the child
Ans: A
Feedback:
Bedtime prayers may be especially important to young children because they lend
security in a strange environment. Hanging a religious picture, providing with a Bible,
and having the hospital chaplain visit will not necessarily provide security to a child in a
strange environment.
15. The nurse is identifying ways to increase the oral fluid intake of a preschool-age child.
Which interventions should the nurse use with this patient? (Select all that apply.)
A) Provide fluids ice cold.
B) Offer small full glasses of fluid.
C) Provide the child's favorite fluid.
D) Encourage popsicles if permitted.
E) Provide a straw if not contraindicated.
Ans: B, C, D, E
Feedback:
Practice guidelines to encourage fluid intake at any age include offering small full
glasses of fluid, provide the favorite fluid, encourage popsicles if permitted, and provide
a straw if not contraindicated. The nurse should try changes in temperature of offered
fluids for variety.
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Chapter 37 Nursing Care of a Family When a Child Needs Diagnostic or
Therapeutic Modalities
1. Which intervention should the nurse use when collecting a urine specimen from an
8-month-old patient?
A) Place a urine collector on the baby just prior to feeding.
B) Wait an hour after a feeding and then apply a collection bag.
C) Wait until the baby voids and attempt to obtain a clean-catch specimen.
D) Place a diaper on the baby; when it is wet then send the diaper to the laboratory.
Ans: A
Feedback:
An infant who has not been toilet trained cannot be expected to urinate on command so
a collecting device must be attached to the genitalia to collect their next voiding. Most
infants void shortly after a feeding, so if the collector is applied just before a regular
feeding, voiding will probably result soon afterward. Remove the collector as soon as
the infant voids and transfer the specimen to a specimen cup by cutting a bottom corner
of the bag. Waiting an hour after a feeding might not produce the needed urine for the
specimen. It would be difficult to obtain a clean-catch specimen from a baby. It is
inappropriate to send a saturated diaper to the laboratory for a urine specimen.
2. The nurse needs to obtain a blood sample from a 7-year-old child. How should the nurse
explain this procedure to the patient?
A) “The doctor needs some of your blood; trust me, it won't hurt.”
B) “I need to draw some blood from you. Will you hold still for me?”
C) “The technician will draw your blood; it will just hurt for a minute.”
D) “The doctor needs to look at your blood to see why you are sick; it will hurt for a
second.”
Ans: D
Feedback:
The nurse should offer the child a simple explanation of the procedure such as, “The
doctor needs to look at your blood to see why you are sick; it will only hurt for a
second.” The nurse needs to let the child know you understand how difficult it is to
agree to the procedure. Saying that the procedure does not hurt is not being truthful.
Asking the patient to hold still does not provide enough of an explanation about the
venipuncture. Saying that the technician is going to draw the blood and that it will only
hurt for a minute does not explain why the blood is needed.
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3. The nurse is preparing a community program for parents and children that focus on the
2020 National Health Goals to reduce the number of diagnostic or therapeutic
procedures. Which topics should the nurse include in this program? (Select all that
apply.)
A) Explain the importance of good nutrition.
B) Emphasize the importance of avoiding unintentional injuries.
C) Include interventions to help prevent children from becoming ill.
D) Discuss the value of having diagnostic testing completed annually.
E) Relate how immunizations continue to be controversial for children.
Ans: A, B, C
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to reduce the
number of diagnostic or therapeutic procedures for children by providing health
counseling to both parent and child on ways to prevent children from becoming ill and
subsequently requiring hospitalization, such as teaching sound nutrition and instructing
on practices on avoiding unintentional injury. The goal is to reduce the number of
diagnostic tests and not encourage them to be done annually. Focusing on the
controversy with immunizations will not support the 2020 National Health Goals.
4. The nurse is caring for an infant recovering from surgery for a cleft palate. Which type
of restraint would be appropriate for the nurse to use when caring for this infant?
A) Elbow
B) Jacket
C) Mummy
D) Clove hitch
Ans: A
Feedback:
The elbow restraint is indicated to prevent children from touching the head or face after
facial surgery. The jacket restraint is to restrain children younger than 6 months in a
supine position. This will not prevent the baby from touching the face. The mummy
restraint temporarily immobilizes young children for a procedure involving the head,
neck, or throat. This might be the restraint used for the surgery but not for the
postoperative care. The clove hitch restraint is used to secure one arm or leg for a
procedure, such as an intravenous infusion.
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5. The nurse needs to assess the temperature of a 12-month-old infant. Which site should
the nurse use for this assessment?
A) Axilla
B) Mouth
C) Rectum
D) Tympanic membrane
Ans: D
Feedback:
Thermometers that assess tympanic membrane temperature are ideal for assessment in
children because they register within 2 seconds and therefore cause less fear because a
child only has to be restrained for a few seconds. The axilla is the preferred site for
temperature assessment for a newborn. The baby is too young to be able to keep an oral
thermometer in the mouth. It is not necessary to use the rectum to measure the
temperature on this child. This approach is too intrusive.
6. The nurse is planning to instruct a school-age child on a barium swallow. What should
the nurse do before beginning this instruction?
A) Encourage the parents to participate in the teaching.
B) Contact the lab to find out when the test is scheduled.
C) Ask the child about ever having a test where something was swallowed.
D) Check the child's medical record for reports of previous diagnostic tests.
Ans: C
Feedback:
Before moving forward with preparation for a diagnostic test, the nurse needs to
determine the child's knowledge about a test or similar tests. Pointing out a child's past
experience with similar procedures can lay a foundation for increased cooperation. The
parents do not necessarily have to participate in this teaching. Learning the time of the
test can be done later. Checking the child's medical record will not help with the child's
learning needs at this present time.
7. What action should the nurse take after collecting a stool specimen for ova and parasites
from a preschool-age child?
A) Refrigerate the specimen.
B) Add alcohol to the specimen container.
C) Have the specimen taken to the laboratory immediately.
D) Discard the specimen if the color is not yellow or green.
Ans: C
Feedback:
If a stool specimen is for ova and parasites, do not refrigerate it because refrigeration
destroys the organisms to be analyzed. The specimen needs to arrive in the laboratory in
less than 1 hour after collection so the parasites can be readily detected. Alcohol should
not be added to the specimen container. The color of the stool sample is of no
consequence.
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8. A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant.
What should the nurse do to assess if the tube is in the patient's stomach?
A) Aspirate the tube for stomach contents.
B) Administer 1 ml of fluid and observe for coughing.
C) Listen at the distal end of the tube for bowel sounds.
D) Lower the end of the tube and observe for drainage.
Ans: A
Feedback:
It is necessary to use a syringe to aspirate the tube for any stomach residual before a
feeding because it confirms the tube's placement in the stomach. Fluid should not be
introduced through the nasogastric tube until placement has been confirmed. Listening
for bowel sound and lowering the tube for drainage are not appropriate techniques to
assess for nasogastric tube placement in an infant.
9. A preschool-age child has not been able to eat for several days until all diagnostic tests
are complete to determine the cause of chronic diarrhea. Which nursing diagnosis
should the nurse identify as being appropriate for the patient at this time?
A) Risk for injury related to intrusive procedures
B) Fear related to new and strange surroundings of procedure rooms
C) Deficient diversionary activity related to hospitalization and frequent procedures
D) Imbalanced nutrition, less than body requirements, related to food restriction for
procedures
Ans: D
Feedback:
Because the child has not been able to eat for several days, the risk for imbalanced
nutrition is high. This is the appropriate diagnosis for the nurse to select at this time.
There is no enough information to determine if the child is at risk for injury, fearful of
procedure rooms, or experiencing a deficiency in diversionary activities.
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10. The nurse instructs the mother of a toddler on the appropriate way to apply heat and
cold to the child's ankle injury. Which statement indicates that instruction has been
effective?
A) “I should apply the ice for 30 minutes followed by an hour of heat.”
B) “I will keep the ice on the child's ankle longer after providing with pain
medication.”
C) “I will spend time with my child and read or play a game while the heat or cold is
applied.”
D) “I will apply the heat to the child's ankle after waiting 10 minutes for the heating
pad to warm.”
Ans: C
Feedback:
One guideline for the application of heat or cold is to supply a special activity for the
child to enjoy while a hot or cold application is in place, such as reading a story or
playing a game, so that the procedure is not viewed as a chore but as a pleasant time in
which to look forward. Ice or heat should not be applied for longer than 20 minutes.
Pain medication can alter the perception of heat or cold, and the child could receive an
injury from the application. To be certain that a heat application is not too hot, it should
be tested with the inner wrist or the dorsal surface of the hand before applying it to the
child.
11. A 13-month-old child is having a dressing changed on a packed leg wound. Which
action from the parents should be encouraged by the nurse during the treatment?
A) Encourage the father to talk quietly to the child.
B) Make sure the father is sitting on a chair near the door.
C) Ask the father to wait outside until the treatment is complete.
D) Have the father hold the child's legs still during the treatment.
Ans: A
Feedback:
At the time of a procedure, the nurse should advocate for parents to be able to
accompany their infant to hospital departments and remain during procedures to offer
support. Some parents may ask to hold their child during a procedure that causes pain,
but do not ask parents to restrain the child during such a procedure. Their role should be
supportive and comforting and not one that causes pain. The father should be sitting
next to the child. The father should be in the room with the child.
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12. Which process should the nurse use to assess the heart rate of a school-age child?
A) Apical pulse for 1 full minute
B) Radial pulse for 1 full minute
C) Femoral pulse for 1 full minute
D) Brachial pulse for 1 full minute
Ans: B
Feedback:
An apical pulse is taken in children younger than 1 year of age because their radial pulse
is too faint to be palpated accurately. After 1 year of age, the radial pulse can be used
and assessed for 1 minute. The femoral and brachial pulses are not used to determine
heart rate of a school-age child.
13. A school-age child is prescribed an enema in preparation for a colonoscopy. Which type
of solution and amount should the nurse prepare for the child?
A) 150 ml normal saline
B) 350 ml normal saline
C) 100 ml tap water enema
D) 250 ml milk and molasses
Ans: A
Feedback:
Normal saline is the usual solution for an enema for a child. For a school-age child, the
amount of solution should be between 300 and 500 ml. Tap water is not used for an
enema because it is not isotonic and can cause rapid shifts of fluids, leading to water
intoxication. Milk of molasses is used to relieve a fecal impaction.
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14. The nurse is providing instructions to the parent of a school-age child who received
conscious sedation for a bronchoscopy. What should the nurse include in this teaching?
(Select all that apply.)
A) Provide an antiemetic if vomiting occurs.
B) Provide the child with something to eat if hungry.
C) Encourage the child to engage in physical activity such as riding a bicycle.
D) Expect to stay with the child for at least 4 hours to ensure dizziness does not
occur.
E) Determine that the child is able to swallow without choking before providing solid
food.
Ans: D, E
Feedback:
The nurse should instruct the parent to stay with the child for at least 4 hours to ensure
dizziness does not occur with walking. The parent should also make sure that the child
can swallow liquids without choking before providing solid food. If vomiting occurs,
the health care provider should be contacted. The child's swallowing ability needs to be
assessed before providing with solid food. Physical activity that requires alertness
should be avoided for 12 hours because the sedation can affect coordination and
balance.
15. The nurse instructs the mother of a preschool-age child on the use of ibuprofen
(Pediaprofen) prescribed for a temperature. Which statement indicates that the teaching
has been effective?
A) “I should give this medication with food.”
B) “I should measure out the dosage using a kitchen teaspoon.”
C) “I should limit the child's fluids while taking this medication.”
D) “I should expect the child to complain of a stomach ache with this medication.”
Ans: A
Feedback:
Because ibuprofen (Pediaprofen) can cause gastrointestinal irritation, it should be given
with food or fluids. The medication dosage should be measured by using the device
supplied with the medication and not using a kitchen spoon. Fluids should be
encouraged when taking this medication because renal failure can occur if the child
becomes dehydrated. If the child complains of a stomachache while taking this
medication, notify the health care provider. This could be an indication of an adverse
effect.
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Chapter 38 Nursing Care of a Family When a Child Needs Medication Administration
1. The nurse is admitting a 4-year-old child to the hospital for surgery. Before
administering medicine, how should the nurse identify this child?
A) Read the child's arm band.
B) Ask the child to state his or her name.
C) Tell the child to state his or her nickname.
D) Say the child's name and see if the child answers.
Ans: A
Feedback:
When asked what is their name, children cannot be depended on to reply with their
correct name. Anxious to please, a preschooler will answer the question, “Are you
Johnny Jones?” with “yes.” The child may also agree with any other name the nurse
states. Stating a nickname would not correctly identify the child.
2. The nurse is planning to provide a preschool-age patient with an oral medication. Which
approach should the nurse use to gain the child's cooperation?
A) Compare the taste of the medicine to a chocolate bar.
B) Offer to play a game with the child if the medicine is swallowed.
C) Ask the child if a cup or oral syringe is preferred to take the medicine.
D) Leave the medicine on the bedside stand; it can be taken independently.
Ans: C
Feedback:
The child should be offered choices to provide a sense of control. Asking if a cup or oral
syringe is preferred is the best approach for the nurse to use to gain the child's
cooperation. Medicine should never be compared to chocolate. The child might eat a
fatal amount of the medicine when unattended. Offering to play a game is bribing the
child and should not be done. The medicine should not be left at the bedside stand. The
child might forget to take it and another child might swallow it.
3. Prior to providing a preschool-age child with a prescribed dose of medication, the nurse
is concerned that the child is underweight. Which should the nurse do at this time?
A) Give the child the prescribed dose.
B) Give the child one half the ordered dose.
C) Call the child's physician and alert to the dosage error.
D) Measure the child's height and weight and check whether the dose is correct.
Ans: D
Feedback:
Before administering any medication to a child, confirm that the dose prescribed is
correct for the child's weight or body surface area. The nurse should not give the child
the prescribed dose or one half the ordered dose. A dosage error has not occurred. The
nurse is just calculating the dose according to the child's current correct weight.
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4. Which technique should the nurse use to administer ear drops to a 4-year-old child?
A) Press the pinna of the ear forward.
B) Pull the pinna of the ear downward.
C) Pull the pinna of the ear up and back.
D) Lift the pinna of the ear down and back.
Ans: C
Feedback:
When administering ear drops, if the child is older than 2 years of age, pull the pinna of
the ear up and back. The pinna should not be pressed forward, pulled downward, or
lifted down and back.
5. The nurse is identifying diagnosis appropriate for a preschool-age child who began to
cry after learning about needing intravenous fluid therapy. Which diagnosis should the
nurse select to address this specific reaction?
A) Fear related to intravenous infusion
B) Discomfort related to intravenous infusion
C) Health-seeking behavior by the child related to the intravenous infusion
D) Deficient knowledge related to actions and effects of intravenous fluid therapy
Ans: A
Feedback:
After learning about needing an intravenous infusion, the child began to cry. The most
appropriate diagnosis would be fear related to intravenous infusion. The infusion has not
started, so the child may or may not experience discomfort related to the infusion. The
child did not ask the nurse to explain the infusion or the actions and effects of fluid
therapy.
6. Which action should the nurse take to ensure an intravenous infusion will be
administered safely to an infant?
A) Add a calibrated fluid chamber to the line.
B) Use a large-bore needle to prevent plugging.
C) Use a rolled pillowcase instead of a hard arm board.
D) Hang the infusion bag no higher than 4 ft above the infant's head.
Ans: A
Feedback:
Overloading of IV fluid in infants can be prevented by use of fluid chambers, devices
that allow only 50 to 100 ml of fluid into the drip chamber at a time. With these in
place, even if the pump fails, only the amount of fluid in the drip chamber will be
allowed to enter the child's circulation, not the entire contents of the bag suspended
above the child's head. A large-bore needle will not ensure that intravenous fluids will
be administered safely to an infant. Using a rolled pillowcase instead of a hard arm
board also will not ensure that intravenous fluids will be administered safely to an
infant. The height of the infusion bag will not ensure that fluids will be administered
safely to an infant.
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7. The nurse manager of an ambulatory well-child clinic is planning an evening lecture
series for community family members that focus on the 2020 National Health Goals for
safe medication administration. What topics should the nurse plan to include in this
lecture series?
A) Storing insulin in the refrigerator
B) Avoiding alcohol use in adolescents
C) Safe medication storage in the home
D) Completing entire course of antibiotics as prescribed
E) Nonpharmacologic ways to reduce stress and anxiety
Ans: B, C, E
Feedback:
The 2020 National Health Goals, which speak to medicine administration, include
reducing the use of alcohol by adolescents and reducing the nonmedical use of
psychotherapeutic drugs. Nurses can help the nation achieve these goals by educating
parents about safe drug storage and teaching children and parents about effective
nonpharmacologic ways to relieve stress or anxiety to help reduce drug dependence.
8. While preparing to insert an intravenous access device into the arm of a school-age
child, the child's mother ask if the device can be placed in the left hand so the child can
do homework with the right hand. What should the nurse respond to the mother?
A) “Let's take a look at the left hand first.”
B) “It's a doctor's decision to decide the best site.”
C) “It would be better for him to wait and be surprised.”
D) “I doubt it; most children have better veins on the right.”
Ans: A
Feedback:
Older children often express a preference regarding where they want an infusion
inserted. The nondominant hand is a good suggestion to provide to the child if a
preference is not requested. The doctor does not decide which arm to insert an
intravenous access device. The child does not need to be surprised with placement of an
intravenous access device. The nurse has no way of knowing which arm or limb will
have better veins for the intravenous access device.
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9. A school-age child is prescribed to receive long-term intravenous antibiotics at home.
Which intravenous access route should the nurse suggest as the best for this patient's
needs?
A) A port in the left upper chest
B) A PICC line in an antecubital space
C) An intraosseous line in the left lower leg
D) A Hickman catheter in the right upper chest
Ans: B
Feedback:
Peripherally inserted central catheters or PICC lines are advantageous for home care
because they can remain in place for up to 4 months without being changed. In a PICC
line, a catheter is inserted into an arm vein and advanced until the tip rests in the
superior vena cava. Drugs commonly administered by PICC lines are antibiotics. The
child does not need a port or Hickman catheter implanted in the chest. An intraosseous
line is not indicated for this child's medication therapy.
10. A toddler with pneumonia is prescribed intravenous fluids and antibiotics. Which type
of intravenous fluid should the nurse expect to provide to this patient?
A) 0.9% normal saline
B) Dextrose 5% in 0.45% normal saline
C) Dextrose 10% in 0.9% normal saline
D) Dextrose 5% in 0.9% normal saline
Ans: A
Feedback:
Intravenous fluid administered to children must be isotonic to prevent destruction of red
blood cells or development of water intoxication. The use of isotonic fluid prevents fluid
shifting from the bloodstream into interstitial tissue or fluid shifting from interstitial
tissue into the bloodstream. A 0.9% normal saline is the IV fluid most commonly used
in children because it is isotonic. Solutions containing 5% dextrose or 10% are
hypertonic and could cause fluid shifting from interstitial tissue into the blood stream.
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11. The nurse teaches the parents of a toddler with prescribed subcutaneous medications
how to provide the medication. Which observation indicates that teaching has been
effective?
A) Inserts the needle at a 90-degree angle
B) Inserts the needle into the gluteal muscle
C) Inserts the needle into the arm when the child is asleep
D) Inserts the needle into the lateral aspect of the vastus lateralis muscle
Ans: D
Feedback:
For subcutaneous injections, the same site should be used as for an intramuscular
injection, which is the vastus lateralis muscle of the anterior thigh. The needle should be
inserted at a 45-degree angle. The gluteal muscle should not be used because of the size
and location of the sciatic nerve. Injections should not be provided to children when
they are asleep.
12. The nurse is reviewing discharge instructions with the family of a child diagnosed with
a urinary tract infection. What should the nurse teach the parents and child about the
prescribed medication?
A) Complete the entire course of antibiotics ordered by the provider.
B) The child may choose to take the antibiotics or stop once symptoms subside.
C) As long as the child does not have a fever, the antibiotics can be stopped.
D) Save the remainder of antibiotics in case the child has another infection.
Ans: A
Feedback:
When a child is uncomfortable or has definite disease symptoms, parents tend to give
medicine conscientiously. However, when symptoms fade, a child returns to school, or
the family returns to its busy everyday schedule, it is easy for parents to forget to give
medicine. This can leave children open to a recurrence of the condition or symptoms,
such as pain or recurrent infection, because the organisms causing the illness were only
suppressed, not killed. Parents need to be reminded to provide the child with the entire
course of the antibiotic prescribed by the provider. The antibiotics should not be saved
for later use. The medication should be taken even if the patient does not have a fever.
The child is not to make the decision regarding taking or not taking the prescribed
antibiotic.
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13. A 6-year-old patient is prescribed to receive an oral antibiotic. What should the nurse do
before giving the child this medication?
A) Check to see if the child can swallow pills.
B) Give the child a small glass of water to drink.
C) Give the child the medicine before the next meal.
D) Tell the child that the medicine can be given as an injection instead.
Ans: A
Feedback:
Many children do not have enough coordination to swallow tablets or pills until they are
6 or 7 years of age. Children younger than 9 years of age often have difficulty
swallowing tablets. This can make getting a child to agree to try an oral medication
difficult. The nurse needs to check to see if the child can swallow pills before providing
the oral medication. Drinking a glass of water before giving the medication will not
determine if the child can swallow an oral medication. Giving the oral medication at the
time of the next meal does not necessarily mean that the child will be able to swallow
the oral medication. The nurse should not threaten to give the medication with an
injection.
14. A toddler is prescribed to receive 50 mg of an antibiotic. The medication available is
250 mg in 5 ml. How many milliliters of the medication should the nurse provide to the
patient? (Enter numeric value only.)
Ans: 1 ml
Feedback:
To calculate a fractional drug dose, the nurse should use the formula:
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15. A school-age child is prescribed to receive 1,500 ml + 20 ml/kg for each additional
kilogram over 20 kg of intravenous fluid over the next 24 hours. The child weighs 55 lb.
How much intravenous fluid should the nurse provide the patient for an 8-hour shift?
(Enter numeric value only. Round to the nearest whole number if applicable.)
Ans: 533 ml
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing 55 lb by
2.2 or 55 / 2.2 = 25 kg. Then the nurse needs to determine how many kilograms of
weight the child is over 20 or 25 kg (current weight) – 20 = 5 kg. Because the child is to
receive 20 ml additional fluid for every kilogram of body weight over 20 kg, the nurse
should then multiply 5 kg × 20 = 100 ml. Then the nurse should set up the equation of
1,500 ml + 100 ml = 1,600 ml. This is the total volume of fluid that the child is to
receive in 24 hours. To determine the amount to provide during an 8-hour shift, the
nurse should divide this total by 3 or 1,600 / 3 = 533.33 ml. When rounded to the
nearest whole number, the nurse will provide 533 ml of fluid over 8 hours.
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Chapter 39 Pain Management in Children
1. The nurse is planning care for a school-age patient experiencing undiagnosed limb pain.
Which nursing diagnoses regarding pain should the nurse consider when designing this
patient's plan of care? (Select all that apply.)
A) Pain related to an invasive procedure
B) Disturbed sleep pattern related to chronic pain
C) Fear related to anticipation of painful procedure
D) Anxiety related to dressing changes that cause pain
E) Health-seeking behaviors related to the cause of pain
Ans: A, B, C
Feedback:
Nursing diagnoses for children with pain focus not only on the pain but also on the
stress, fear, or anxiety that pain produces. Nursing diagnoses appropriate for the child
experiencing undiagnosed limb pain include pain related to an invasive procedure,
disturbed sleep pattern related to chronic pain, and fear related to anticipation of painful
procedure. It is unknown if the child has a dressing on the limb. The child is
demonstrating health-seeking behaviors related to the cause of the pain.
2. The community nurse is planning a program that focuses on the 2020 National Health
Goals to alleviate pain. Which information should the nurse include that focuses on pain
control in children? (Select all that apply.)
A) Encourage all episodes of pain to be treated with narcotics.
B) Instruct on avoiding unintentional injuries by using safety belts and helmets.
C) Explain that pain can be managed with medicine or nonmedication measures.
D) Remind that the use of over-the-counter analgesics like aspirin are recommended.
E) Recommend that the use of alternative pain medications on the market be used for
pain.
Ans: B, C
Feedback:
Nurses can help the nation reduce pain among children by active management of pain as
well as teaching children about the importance of avoiding painful unintentional injures
by the use of safety belts and bicycle helmets. One 2020 National Health Goals is to
reduce the number of non–FDA-approved pain medications on the market. Another
2020 National Health Goal is to reduce the incidence of injuries caused by pain
medication. Over-the-counter analgesics like aspirin are not recommended for all
episodes of pain.
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3. Prior to conducting a blood-drawing procedure, the nurse teaches a child to imagine
swimming in a cool, shady park with friends and family. Which technique did the nurse
use with this patient?
A) Imagery
B) Park therapy
C) Thought stopping
D) Nerve stimulation
Ans: A
Feedback:
Substitution of meaning or guided imagery is a distraction technique to help a child
place a nonpainful meaning onto a painful procedure. Children are often more adept at
imagery than adults because their imagination is less inhibited. This technique works
well with quick, simple procedures such as venipunctures or chronic pain. Park therapy
is not a pain management technique. This technique is not thought stopping or nerve
stimulation.
4. The nurse is preparing to provide a preschool-age child with an injection. Which
technique should the nurse use when applying EMLA cream to the injection site?
A) Apply it at least 1 hour before the procedure.
B) Wipe it off at least 15 minutes before the procedure.
C) Apply it immediately prior to the painful procedure.
D) Do not cover it after application to prevent it from discoloring.
Ans: A
Feedback:
EMLA is a topical anesthetic cream containing lidocaine and prilocaine. The nurse
should apply a dollop of the cream on the intended site at least 1 hour before the
injection. The cream should be removed immediately before the injection. The cream
needs time to work so applying immediately before the injection will not help reduce
pain. The cream is covered to keep it secure over the intended area. The cream will not
discolor when covered.
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5. The nurse is preparing discharge teaching for the parents of a school-age child who was
recently receiving patient-controlled analgesia. What should the nurse include when
teaching the parents about pain management for this patient? (Select all that apply.)
A) Dosing of pain medication
B) Frequency of pain medication
C) Expected level of pain relief
D) Contact number to call with questions
E) Technique to insert an intravenous line
Ans: A, B, C, D
Feedback:
For ongoing care, the nurse should ensure that children and parents are provided with
support and follow-up to the extent necessary to continue adequate pain management in
the home. Parents should be given instructions on dosing, administration, frequency,
expected outcomes, and expected level of relief. Provide them with the name and
telephone number of a health care professional whom they can call if they have
questions about pain management. The parents are not responsible for inserting an
intravenous line.
6. The nurse is assessing for pain in a 2-month-old infant. Which behavior indicates that
this baby is experiencing pain?
A) Sleeping longer during naps
B) Crying when put on abdomen
C) Decreased intake with each feeding
D) Continued crying after diaper change and being fed
Ans: D
Feedback:
The chief indication of pain in infants is the inability to be comforted when pain is
present. Typical comfort measures such as diaper changing and feeding are not soothing
to the child. Sleeping, crying when placed on the abdomen, and a decreased intake do
not indicate that the child is experiencing pain.
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7. A school-age child with a fractured leg is crying. The child will not move the extremity,
lies very still, and denies the presence of pain. What should the nurse recognize as the
possible reason for this child's behavior?
A) The child is scared.
B) The child is afraid of the hospital and personnel.
C) An injection was given for pain in the emergency room.
D) The child is anticipating punishment for breaking the leg.
Ans: C
Feedback:
If a child is reluctant to admit the presence of pain because of the fear of receiving an
injection, another form of analgesia needs to be determined. The child's behavior
indicates pain. This behavior is not consistent with being scared or afraid of the hospital.
There is no information to support that the child is awaiting punishment for breaking the
leg.
8. The nurse is preparing to conduct a health history with the parents of a preschool-age
child admitted for an appendectomy. Which questions should the nurse plan to use to
learn more about the child's ability to manage pain? (Select all that apply.)
A) “How does your child usually react to pain?”
B) “How do you know when your child is in pain?”
C) “Does your child use pain as a control mechanism?”
D) “Are you concerned about addiction to pain medication?”
E) “What do you do for your child when your child is hurting?”
Ans: A, B, E
Feedback:
When conducting a pain experience inventory with parents, the nurse should ask how
the child usually reacts to pain, how the parents know that the child is in pain, and what
the parents do when the child is in pain. Questions not appropriate for this inventory
include asking if the child uses pain as a control mechanism and if the parents are
concerned about addiction to pain medication.
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9. The nurse is using a postoperative pain management scale to determine if a newborn
recovering from emergency surgery is experiencing pain. Which observations indicate
that the child is experiencing level 3 pain this time? (Select all that apply.)
A) High-pitched cry
B) Baby is grimacing
C) Baby has not fallen asleep
D) Heart rate elevated to greater than 20% over the baseline
E) Baby falls asleep for short periods and then wakes up crying
Ans: A, C, D
Feedback:
Observations that the infant is experiencing pain at a level 3 include a high-pitched cry,
not sleeping, and a heart rate elevated to greater than 20% over the baby's baseline.
Grimacing and falling asleep for short periods indicate pain at a level 2.
10. An adolescent is being evaluated for appendicitis. When assessed for pain, the patient
points to the lower left abdominal region. What type of pain should the nurse document
that this patient is experiencing?
A) Somatic pain
B) Chronic pain
C) Referred pain
D) Cutaneous pain
Ans: C
Feedback:
Referred pain is pain that is perceived at a site distant from its point of origin. Somatic
pain is pain that originates from deep body structures such as muscles or bones. Chronic
pain is pain that lasts for a prolonged period or beyond the time span anticipated for
healing. Cutaneous pain is pain that arises from superficial structures such as the skin
and mucous membrane.
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11. During a home visit, the mother of a child with chronic pain is distraught because the
child always seems to be uncomfortable despite receiving pain medication as prescribed.
What should the nurse instruct the mother to do to help this child's pain? (Select all that
apply.)
A) Offer a back rub or other comfort measures.
B) Stay with the child and offer love and support.
C) Suggest the child learn to deal with the pain and grow up.
D) Provide pain medication with a positive expectation that it will take the pain
away.
E) Ask the child what might help relieve the pain, such as extra pillows or a warm
drink.
Ans: A, B, D, E
Feedback:
Strategies to help a child with pain at home include offering a back rub or other comfort
measures, staying with the child and offering love and support, providing pain
medication with the expectation that it will take the pain away, and asking the child to
explain what might help relieve the pain. Saying that the child needs to grow up can
possibly shame the child and does not help deal with the pain.
12. The nurse is planning to assess the amount of pain that a 15-year-old child is
experiencing after a motor vehicle crash. Which pain scale should the nurse use to
measure this patient's pain?
A) CRIES
B) FACES
C) Adolescent Pediatric Pain Tool
D) The COMFORT Behavior Scale
Ans: C
Feedback:
The Adolescent Pediatric Pain Tool combines a visual activity and a numerical scale.
On one half of the form is an outline figure showing the anterior and posterior view of a
child. To use the tool, tell a child to color in the figure, drawing at the point where pain
is felt. In addition, on the right side of the form, tell the child to rate present pain in
reference to “no pain,” “little pain,” “medium pain,” “large pain,” and “worst possible
pain.” For a third activity, tell children to point to or circle as many words as possible on
the form that describe their pain. The scale is suggested for use in children 8 through 17
years of age. The CRIES tool and COMFORT Behavior Scale are tools appropriate for
use with infants. The FACES tool is appropriate for use with small children starting
around age 3 years.
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13. The nurse wants to assess the amount of pain a preadolescent with scoliosis experiences
throughout the day. Which tool should the nurse use to make this assessment?
A) Logs and diaries
B) FACES Pain Rating Scale
C) Adolescent Pediatric Pain Tool
D) Numerical or Visual Analog Scale
Ans: A
Feedback:
Having children keep logs or diaries in which they note when pain occurs and the
intensity of the pain each time it occurs can be useful for assessing children with chronic
but intermittent pain. Examining such a diary not only reveals when pain occurs but also
provide direction for pain management. The FACES tool is appropriate to assess the
pain level of small children starting around age 3 years. Although appropriate for a
preadolescent child, the Adolescent Pediatric Pain Tool assesses one episode of pain.
The Numerical or Visual Analog Scale also assesses the amount of pain during one
episode in time.
14. While the phlebotomist draws blood from a toddler's right arm, the nurse is having the
child blow bubbles with the left hand. Which pain management technique is the nurse
using with the child?
A) Imagery
B) Hypnosis
C) Distraction
D) Thought stopping
Ans: C
Feedback:
Distraction techniques aim at shifting a child's focus from pain to another activity or
interest. Blowing soap bubbles is an example of distraction. Substitution of meaning or
guided imagery is a distraction technique to help a child place another meaning on a
painful procedure. Hypnosis is not a common pain management technique with children
but can be effective if a child is properly trained in the technique so that the child can
produce a trancelike state to effectively avoid sensing pain. Thought stopping is a
technique in which children learn to stop anxious thoughts by substituting a positive or
relaxing thought in its place.
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15. The nurse teaches a mother pain management techniques to use for a toddler with otitis
media. Which statement indicates that the mother needs additional teaching?
A) “I should give my toddler one baby aspirin.”
B) “Use of infant Tylenol is good for my toddler.”
C) “I don't have to give my child pain medication unless it is needed.”
D) “Ibuprofen can be purchased over the counter to use if my toddler needs it.”
Ans: A
Feedback:
Children should not receive acetylsalicylic acid or aspirin for pain relief because there is
an association between aspirin administration and the development of Reye syndrome.
Infant Tylenol and ibuprofen are safe to use with children for pain control. The child
should not receive pain medication unless it is needed.
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Chapter 40 Nursing Care of a Family When a Child Has a Respiratory Disorder
1. The nurse is planning a community program for parents that focuses on the 2020
National Health Goals to reduce of respiratory illness in children. Which information
should the nurse emphasize in this presentation? (Select all that apply.)
A) Adhering to recommended immunizations
B) Engaging in age-appropriate activity daily
C) Importance of avoiding all cigarette smoking
D) Ensuring an adequate dietary intake of calcium products
E) Role of good hand washing to reduce transmission of disease
Ans: A, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to reduce respiratory
illness in children by teaching children to avoid cigarette smoking, ways to help avoid
respiratory infections such as good hand washing, and reminding parents to come for
child health maintenance visits so that children can receive pneumococcal immunization
or screening for tuberculosis, as appropriate. Activity and nutrition are not identified as
interventions to reduce the risk of respiratory illness in children.
2. The nurse is caring for a school-age child with laryngotracheobronchitis. Which action
aids in bronchodilation to improve breathing for this child?
A) Administering an oral analgesic
B) Urging the child to take oral fluids
C) Teaching the child to take long, slow breaths
D) Assisting with racemic epinephrine nebulizer therapy
Ans: D
Feedback:
When caring for a child with laryngotracheobronchitis, cool moist air combined with
racemic epinephrine through a nebulizer usually reduces inflammation and produces
effective bronchodilation to open the airway. An oral analgesic is not necessary because
the child is not experiencing throat pain. The child may not be able to take fluids orally
at this time. Intravenous therapy could be indicated to maintain adequate hydration and
thin respiratory secretions. The child is experiencing air hunger and will not be able to
take long slow breaths.
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3. The nurse is caring for a preschool-age child with acute nasopharyngitis. Which
information should the nurse include when teaching the parents about this health
problem?
A) Healthy children rarely have more than one cold per year.
B) Typically, the child will pull the ear when a cold is present.
C) A cough that accompanies a cold should rarely be suppressed.
D) An antibiotic is prescribed for children younger than 5 years of age.
Ans: C
Feedback:
When caring for a child with acute nasopharyngitis, or the common cold, the nurse
should teach the parents that cough suppressants are not necessary because coughing
raises secretions, preventing pooling of secretions and the danger of consequent lower
respiratory infection. Healthy children can have more than one cold per year. Pulling on
the ear indicates an ear infection. Antibiotics are not prescribed unless a bacterial
infection is present.
4. The nurse is making a follow-up visit to the home of a family with a baby newly
diagnosed with cystic fibrosis. Which outcome indicates that the parents are adjusting to
the child's care needs?
A) Baby has gained weight.
B) Baby's foul-smelling stool.
C) Baby produces large stool twice a day.
D) Baby appears flushed and is warm to touch.
Ans: A
Feedback:
Children with cystic fibrosis need pancreatic enzyme replacements to help absorb
nutrients. The baby gaining weight indicates that these supplements are effective.
Foul-smelling stool indicates that additional intervention is needed because fat is not
being absorbed. Large stools indicate that nutrients are not being adequately absorbed.
Flushing and warmth could indicate a fever or that the home environment is too warm
for the child. If children with cystic fibrosis become overheated, they begin to lose
excessive sodium and chloride through perspiration and become dehydrated.
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5. While providing care, a school-age child develops epistaxis. What should the nurse do
to help this patient?
A) Turn the child's head to the side and press on the nasal ridge.
B) Sit the child upright and apply pressure to the sides of the nose.
C) Keep the child flat and apply pressure to the bridge of the nose.
D) Elevate the head of the bed slightly and apply pressure to the forehead.
Ans: B
Feedback:
The nurse keeps the child with a nosebleed in an upright position with the head tilted
slightly forward to minimize the amount of blood pressure in nasal vessels and to keep
blood moving forward, not back into the nasopharynx. Then the nurse should apply
pressure to the cartilage on the sides of the nose with the fingers for about 10 minutes.
The head should not be turned. The child should not be in a flat position. Applying
pressure to the forehead will not stop the flow of blood from the nose.
6. A school-age child is diagnosed with streptococcal pharyngitis. What should the nurse
teach the parents about the care that this child will need at home?
A) Expect the lymph nodes to swell and obstruct the airway.
B) Regular activity level should be encouraged as soon as possible.
C) Be aware that the infection may spread and cause a tooth abscess.
D) Complete the entire course of antibiotics to prevent rheumatic fever.
Ans: D
Feedback:
The nurse should help parents understand the importance of completing the full
prescribed days of therapy in order to ensure all the streptococci are eradicated. If they
are not, the child may develop a hypersensitivity or autoimmune reaction to group A
streptococci that can result in rheumatic fever. Lymph node swelling should not occur if
antibiotic therapy is initiated and continued as prescribed. The nurse should instruct
parents about the importance of rest. This type of infection is not known to cause tooth
abscesses.
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7. A school-age child is scheduled for a tonsillectomy. What should the nurse assess prior
to the surgery being done?
A) Urine specific gravity
B) Pulse and respiratory rate
C) Bleeding and clotting time
D) Lying and sitting blood pressure
Ans: C
Feedback:
During a tonsillectomy, tonsillar tissue is removed by ligation or by laser surgery.
Because sutures are not usually placed, the chance for hemorrhage after this type of
surgery is higher than after surgery involving a closed incision. The danger of aspiration
of blood at the time of surgery and the danger of a general anesthetic also compound the
risk. The patient's bleeding and clotting times should be reviewed prior to surgery to
reduce the risk of postoperative hemorrhage. Urine specific gravity is not impacted by a
tonsillectomy. Pulse, respiratory rate, and blood pressure measurement are a part of
routine vital sign assessment. These measurements do not impact the care of the patient
having a tonsillectomy.
8. The nurse is assessing a school-age child with asthma. Which assessment finding
indicates that this patient's asthma is well controlled?
A) Dry mucous membranes
B) Presence of a dry hacking cough
C) Peak flow meter reading in the green zone
D) Audible wheezes present over upper lobes
Ans: C
Feedback:
A peak flow meter reading in the green zone means no asthma symptoms are present.
Dry mucous membranes indicate dehydration, which could reduce expectorating mucus
from the lungs. A dry hacking cough indicates dry mucous membranes and reduces
ability to expectorate mucus from the lungs. Audible wheezes over the upper lobes
means the airways are constricted and an exacerbation of asthma might occur.
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9. The nurse is teaching a 14-year-old child on the proper use of a meter-dose inhaler to
control symptoms of asthma. Which teaching points should the nurse include in these
instructions? (Select all that apply.)
A) Take two puffs at a time.
B) Shake the canister before using.
C) Wait 5 minutes between puffs.
D) Hold the breath for 5 to 10 seconds.
E) Activate the inhaler while taking a deep breath.
Ans: B, D, E
Feedback:
The nurse should instruct the child to shake the canister, exhale deeply, activate the
inhaler while inhaling, take a long slow inhalation, and then hold the breath for 5 to 10
seconds. The child should be instructed to take only one puff at a time and to wait for 1
minute between puffs.
10. The nurse is preparing discharge instructions for a school-age child with a
tracheostomy. On what should the nurse focus when teaching the parents about the
child's care needs at home? (Select all that apply.)
A) Performing tracheostomy care
B) Comfort level with suctioning procedure
C) Eliminate the use of room freshener sprays to reduce tracheal irritation
D) Importance of encouraging independence in the child as soon as possible
E) Obtaining a spare tracheostomy tube and inserter in the event of accidental
removal
Ans: A, B, C, E
Feedback:
The nurse should ensure that the parents are comfortable performing tracheostomy care
and suctioning. The parents need to understand the need to eliminate sprays that could
irritate the child's tracheal mucosa and to have a spare tracheostomy tube and inserter
available in the event the current device is accidentally removed. The child needs to be
monitored for adequate oxygenation, safety when eating, and activity tolerance.
Encouraging independence might need to be postponed until the child's respiratory
status stabilizes.
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11. A 3-year-old child is experiencing localized wheezing upon auscultation. Which
statement by the mother would be most important for the nurse to report to the health
care provider?
A) The child was eating peanuts earlier in the day.
B) The child eats hard candy as an afternoon treat.
C) The child has two cousins who have many allergies.
D) The child likes to play by himself for 15 minutes every afternoon.
Ans: A
Feedback:
The child is demonstrating signs of bronchial obstruction. After aspirating a small
foreign body, the child generally coughs violently and may become short of breath.
Localized wheezing may occur. Because this is localized, it is different from the
generalized wheezing of a child with asthma. Hard tack candy is usually larger in size
than a peanut. Localized wheezing is not a manifestation of allergies. Solitary play may
or may not be important. It depends on the size of the toys that the child has for play and
if any could be accidentally aspirated.
12. The nurse is concerned that a school-age child is developing pneumonia. What did the
nurse most likely assess in this patient? (Select all that apply.)
A) Rales
B) Wheezing
C) Elevated temperature
D) Paroxysmal dry cough
E) Productive harsh cough
Ans: A, C, E
Feedback:
Manifestations of pneumonia include rales, elevated temperature, and a productive harsh
cough. Wheezing is a manifestation of asthma. A paroxysmal dry cough is a
manifestation of bronchiolitis.
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13. A school-age child with asthma is prescribed cromolyn sodium. What should the nurse
include when teaching the child and the parents about this medication? (Select all that
apply.)
A) Use this medication with a metered-dose inhaler.
B) Take this medication before an inhaled bronchodilator.
C) Repeat doses of this medication until symptoms subside.
D) This medication is to be used for an acute asthma attack.
E) Wait 1 to 2 minutes between puffs when taking this medication.
Ans: A, E
Feedback:
Cromolyn sodium should be used with a metered-dose inhaler, and the child should wait
1 to 2 minutes between puffs when taking this medication. This medication should be
taken after a bronchodilator. Doses should not exceed the number of ordered puffs
because tolerance can develop. This medication is not effective in an acute attack.
14. The nurse is evaluating teaching provided to a school-age child and parents about the
medication pancrelipase (Cotazym) for cystic fibrosis. Which observation indicates that
teaching has been effective?
A) The child chews an enteric form of the medication.
B) The child takes a dose before having an afternoon snack.
C) The father tells the child that diarrhea is expected with this medication.
D) The mother opens the capsule and some medication spills on the fingers.
Ans: B
Feedback:
The enzyme replacement pancrelipase (Cotazym) is used for the treatment of cystic
fibrosis. Evidence that teaching has been effective is the child taking a dose of the
medication before having an afternoon snack because this medication is to be taken
before all meals and snacks. The enteric form of the medication should not be chewed.
Diarrhea is an adverse effect of this medication and should be reported to the health care
provider. This medication should not be spilled on the skin because it may irritate the
skin.
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15. The nurse is identifying nursing diagnosis appropriate for a child with pneumonia.
Which diagnosis is the most applicable during the acute phase of the illness?
A) Pain related to swelling of abdominal lymph nodes
B) Altered urinary elimination related to hypervolemic state
C) Excess fluid volume related to excessive mucus production
D) Activity intolerance related to poor oxygen–carbon dioxide exchange
Ans: D
Feedback:
Pneumonia interferes with the exchange of oxygen and carbon dioxide in the lung
alveoli. This can lead to fatigue and generalized activity intolerance. Pain is not a typical
manifestation of pneumonia. Hypervolemia is not associated with pneumonia. Excess
fluid volume is also not associated with pneumonia.
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Chapter 41 Nursing Care of a Family When a Child Has a Cardiovascular Disorder
1. The nurse is caring for a newborn diagnosed with patent ductus arteriosus. Which
finding will the nurse assess that is consistent with this diagnosis?
A) Slow heart rate
B) Expiratory grunt
C) Wide pulse pressure
D) Absent femoral pulses
Ans: C
Feedback:
On physical examination, the child with patent ductus arteriosus usually has a wide
pulse pressure. The diastolic pressure is low because of the shunt or runoff of blood,
which reduces resistance. Manifestations of patent ductus arteriosus do not include a
slow heart rate, expiratory grunt, or absent femoral pulses.
2. Which of the following nursing diagnoses would best apply to a child during the acute
phase of rheumatic fever?
A) Disturbed sleep pattern related to hyperexcitability
B) Ineffective breathing pattern related to cardiomegaly
C) Risk for self-directed violence related to development of cerebral anoxia
D) Activity intolerance related to inability of heart to sustain extra workload
Ans: D
Feedback:
The course of rheumatic fever is about 6 to 8 weeks. Children are maintained on bed
rest only during the acute phase of illness until the pulse rate returns to normal. Because
pulse rate is a valuable sign of improvement, monitoring vital signs is essential during
and following the acute phase. Obtain an apical pulse for a full minute for best results.
Taking it while the child is asleep as well as when the child is awake helps to measure
the effect of activity on the pulse rate; another way to judge inflammation is decreasing
and the child's heart action is improving. Chorea occurs in some children with rheumatic
fever; however, it is not known if this manifestation will disturb the child's sleep.
Children with rheumatic fever may develop congestive heart failure; however,
cardiomegaly is not a long-term effect of the disease. The child is not at risk for
self-directed violence because cerebral anoxia is not a manifestation of the disease.
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3. The nurse is planning a program for community family members that focuses on the
2020 National Health Goals to improve cardiovascular health. Which content should the
nurse include in this program? (Select all that apply.)
A) Measures to reduce obesity
B) Importance of daily exercise
C) Starting reduced-fat diets upon birth
D) Engaging in stress-reduction activities
E) Following a diet that supports heart function
Ans: A, B, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals by educating parents
and children about the importance of reducing obesity and planning exercise and
nutrition programs for sound cardiovascular health. Parents should be cautioned not to
start their children on reduced-fat diets until they are 2 years old to allow for
myelination of nerve cells. Stress-reduction activities are not identified as actions to
achieve the 2020 National Health Goals for cardiovascular health.
4. A newborn is diagnosed with coarctation of the aorta. Which assessment should the
nurse make when caring for this infant?
A) Observing for excessive crying
B) Auscultating for a cardiac murmur
C) Assessing for the presence of femoral pulses
D) Recording an upper extremity blood pressure
Ans: C
Feedback:
If the coarctation is slight, absence of palpable femoral pulses from the decreased blood
pressure in the lower body may be the only symptom seen. To help detect this, the nurse
should always include evaluation of femoral pulses in all initial newborn assessments
and admission inspections to newborn nurseries. Excessive crying, cardiac murmur, and
blood pressure changes are not manifestations of coarctation of the aorta.
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5. What should the nurse teach the parents of a child with tetralogy of Fallot to do if the
child suddenly becomes cyanotic and dyspneic?
A) Place in a knee–chest position.
B) Lie prone and maintain the airway.
C) Lie supine with the head turned to one side.
D) Place in a semi-Fowler's position in an infant seat.
Ans: A
Feedback:
Parents need to try to keep hypercyanotic episodes to a minimum and learn what steps
to take if one should occur. Placing the baby in a knee–chest position to trap blood in
the lower extremities and keep the heart from being overwhelmed generally reduces
symptoms. Lying prone, supine, or in the semi-Fowler's position will not help reduce
cyanosis and dyspnea.
6. Which health teaching concept should the nurse emphasize when instructing the parents
of a child with polycythemia caused by a congenital heart disorder?
A) Prepare for seizures.
B) Prevent dehydration.
C) Expect the skin to turn yellow.
D) Encourage progressive activity.
Ans: B
Feedback:
Hydration must be monitored so dehydration does not occur in children with
polycythemia so the polycythemia does not become so severe clotting or
thrombophlebitis results. Seizures are not a threat with polycythemia. Jaundice is not
associated with polycythemia. Encourage parents to observe the infant carefully when
new activities are introduced so they can recognize the first signs of respiratory distress
or the point at which the child is beginning to exceed exercise tolerance.
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7. The nurse instructs the parents of a child with a congenital heart disorder on the
administration of digoxin at home. Which observation indicates that teaching has been
effective?
A) The father provides a dose of the medication after the baby spits it up.
B) The father provides a dose of the medication at the conclusion of a feeding.
C) The mother feels for a radial pulse before giving the baby the next scheduled
dose.
D) The mother provides a dose of the medication 1 hour before the next scheduled
feeding.
Ans: D
Feedback:
Guidelines to ensure safe digoxin administration at home include providing a dose of
the medication 1 hour before the next scheduled feeding. If a dose is vomited, do not
repeat the dose. The medication should be given 2 hours after a feeding and not
immediately after. The apical heart rate and not the radial pulse should be assessed
before providing a dose of the medication.
8. The parents of a child having a cardiac catheterization are waiting to see the child after
the procedure. What should the nurse instruct the parents to expect when seeing the
child for the first time?
A) The child will be sleeping for at least 8 hours.
B) A bulky pressure dressing will be present over the insertion site.
C) The child will have bruising over the upper and lower extremities.
D) The child will be on seizure precautions and have padded side rails.
Ans: B
Feedback:
When a child returns from a cardiac catheterization, a pressure dressing will be present
over the catheter insertion site. This dressing is snug and will be checked to ensure that
no bleeding is occurring. The child may or may not be sleepy after the procedure. The
child will not have bruising over the upper and lower extremities. Seizure precautions
are not necessary after a cardiac catheterization.
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9. The nurse is planning care for an 8-month-old infant with a ventricular septal defect.
Which nursing diagnosis should the nurse use to help guide the care for this patient?
A) Impaired gas exchange related to a right-to-left shunt
B) Impaired skin integrity related to poor peripheral circulation
C) Ineffective airway clearance related to altered pulmonary status
D) Ineffective tissue perfusion related to inefficiency of the heart as a pump
Ans: D
Feedback:
Ventricular septal defect is the most common type of congenital cardiac disorder. With
this disorder, an opening is present in the septum between the two ventricles. Blood
shunts from left to right across the septum impairing the efficiency of the heart because
blood that should be forced into the aorta and out to the body from contraction of the
left ventricle shunts back into the pulmonary circulation, resulting in right ventricular
hypertrophy and increased pressure in the pulmonary artery. This disorder does not
impair gas exchange, cause impaired skin integrity, or cause ineffective airway
clearance.
10. An infant is prescribed digoxin. What should the nurse explain to the parents regarding
the action of this medication?
A) Increases the heart rate
B) Slows and strengthens the heartbeat
C) Thickens the walls of the myocardium
D) Prevents subacute bacterial endocarditis
Ans: B
Feedback:
Digoxin, a cardiac glycoside made from digitalis, acts directly on the heart to increase
the contractility of the myocardium and the force of contraction to slow the heart rate.
Digoxin does not increase the heart rate, thicken the walls of the myocardium, or
prevent subacute bacterial endocarditis.
11. The nurse is assessing the heart rate of a child with a congenital heart defect. What
should the nurse document when a pulse of one strong beat and one weak beat is
assessed?
A) Dicrotic pulse
B) Thready pulse
C) Pulsus alternans
D) Water hammer pulse
Ans: C
Feedback:
Pulsus alternans is a pulse of one strong beat and one weak beat. Dicrotic pulse is a
double radial pulse for every apical beat. Thready pulse is weak and usually rapid.
Water hammer pulse is very forceful and bounding with capillary pulsations apparent
even in the fingernails.
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12. Which action should the nurse implement for an infant who develops heart failure?
A) Restricting daily milk intake
B) Keeping in a supine position
C) Planning ways to reduce salt intake
D) Placing in a semi-Fowler's position
Ans: D
Feedback:
Most children with heart failure feel more comfortable in a semi-Fowler's position than
in a supine position because the chest-elevated position lowers the abdominal contents,
enlarging the thoracic cavity and allowing easier, more comfortable lung expansion. A
child with heart failure does not need a milk restriction. The supine position will not
help with lung expansion. An infant does not have a significant intake of salt.
13. The nurse is caring for a child with chest tubes inserted after heart surgery that are
attached to an underwater-seal drainage system. For which reason should the nurse
prepare to clamp the chest tubes?
A) The child is coughing.
B) A clot obstructs the tubing.
C) A tube becomes disconnected.
D) Red-stained drainage appears in a tube.
Ans: C
Feedback:
If a tube becomes disconnected creating an air leak, clamp the tube close to the child's
chest to prevent further air from entering the chest. The chest tube should not be
clamped if the child is coughing, a clot is in the tubing, or red-stained drainage appears
in the tube.
14. The cardiac monitor of a child recovering from heart surgery alarms, and the nurse finds
the child without a heartbeat. What should the nurse do first?
A) Apply oxygen.
B) Establish an airway.
C) Begin rescue breathing.
D) Begin cardiac compressions.
Ans: D
Feedback:
The steps for resuscitation can be remembered as “CAB”—chest compressions, airway,
and breathing—and the critical first elements of cardiopulmonary resuscitation are chest
compressions and early defibrillation. Establishing an airway, rescue breathing, and the
use of oxygen are performed in sequence after compressions are started.
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15. A toddler is diagnosed with a functional heart murmur. What should the nurse explain to
the child's parents about this murmur?
A) This type of murmur is innocent.
B) Mild activity restrictions are indicated.
C) More frequent health appraisals are indicated.
D) Corrective surgery may be required later in life.
Ans: A
Feedback:
Murmurs of no significance are termed functional, insignificant, or innocent murmurs.
In discussing such murmurs with parents, the term innocent heart murmur is best to use
because it most clearly describes that the sound heard is not important or is nothing to
worry about. Activity restrictions, frequent health appraisals, and corrective surgery are
not indicated for a functional heart murmur.
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Chapter 42 Nursing Care of a Family When a Child Has an Immune Disorder
1. A child is experiencing anaphylactic shock. Which nursing action is a priority?
A) Facilitate breathing.
B) Counteract hypertension.
C) Enhance the action of histamine.
D) Reverse sympathetic nervous system responses.
Ans: A
Feedback:
In anaphylactic shock, the child has symptoms caused by the stimulation of histamine.
Bronchospasm can become so severe the child becomes dyspneic, hypoxemic, and then
hypoxic. Facilitating breathing is the priority. The blood pressure falls in anaphylactic
shock. A goal of therapy is to reverse parasympathetic nervous system responses.
2. The nurse is planning a program for community members that focus on the 2020
National Health Goals for allergies and immunologic functioning. What content should
the nurse include in this program? (Select all that apply.)
A) Promote following safe sexual practices.
B) Discourage the use of intravenous substances.
C) Discuss the role of sexual relations in HIV transmission.
D) Explain how certain foods promote immunologic compromise.
E) Encourage parents to discuss the air quality in the schools with the school district.
Ans: A, B, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for allergies and
immunologic functioning by advocating for improved air quality in schools, initiating
educational programs for children and adolescents that include teaching about the way
HIV is transmitted, such as through sexual relations and unclean intravenous needles,
and protective measures they can take to avoid contracting the disease, including safer
sex practices and not using intravenous drugs. Explaining how certain foods promote
immunologic compromise does not support the 2020 National Health Goals for allergies
and immunologic functioning.
3. The nurse is preparing to administer subcutaneous epinephrine hydrochloride
(Adrenalin) 0.01 mg/kg to a child weighing 88 lb. How many milliliters of the
medication will the nurse provide? (Numeric value only. Calculate to the10th decimal
point.)
Ans: 0.40 mg
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing the
weight in pounds by 2.2 or 88 / 2.2 = 40 kg. Then the nurse is to multiply the dose of
0.01 mg by the weight or 0.01 mg × 40 kg = 0.40. The nurse is to provide the patient
with 0.40 ml of the medication.
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4. The nurse is caring for a child diagnosed with category B HIV. What should the nurse
expect to review in this patient's medical history? (Select all that apply.)
A) Pneumonia
B) Herpes zoster
C) Kaposi sarcoma
D) Cardiomyopathy
E) Positive tuberculosis test
Ans: A, B, D
Feedback:
In category B HIV, the patient will experience serious illnesses such as pneumonia,
cardiomyopathy, and herpes zoster. Kaposi sarcoma and tuberculosis are associated with
category C HIV.
5. The nurse is preparing educational materials for a group of new parents about allergic
reactions. Which specific immunoglobulin should the nurse emphasize as being
responsible for these types of reactions?
A) IgA
B) IgE
C) IgG
D) IgM
Ans: B
Feedback:
IgE is involved in immediate hypersensitivity reactions and is associated with allergy
and parasitic infections. IgA is found in saliva, sweat, and tears and provides defense
against pathogens on exposed surfaces. IgG is the most frequently occurring antibody in
plasma and neutralizes bacterial toxins. IgM lyses cell walls and is early to arrive in the
presence of an infection in the bloodstream.
6. The nurse is teaching the parents of a child with multiple environmental allergies on
ways to control allergens in the home. What should the nurse include in these
instructions? (Select all that apply.)
A) Remove all carpeting.
B) Install a dehumidifier in the home.
C) Consider having fish as pets instead of a dog or cat.
D) Remove stuffed toys unless filled with synthetic material.
E) Replace furniture with upholstered chairs and sofas for sitting.
Ans: A, B, D
Feedback:
Actions to control environmental allergens include removing all carpeting in the home,
installing a dehumidifier, and only permitting stuffed toys filled with synthetic material.
Fish and aquariums should be removed because they cause mold spores. Upholstered
chairs and sofas should be replaced with wooden chairs and surfaces.
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7. A 6-month-old baby diagnosed with atopic dermatitis has been receiving treatment by
the parents. Which approach that the parents are using indicates that additional health
teaching is necessary?
A) After a bath, the mother applies Eucerin cream.
B) To dry lesions, the father applies alcohol to lesions daily.
C) The mother gives the baby a daily bath without using soap.
D) To aid healing, the father applies hydrocortisone cream to the lesions.
Ans: B
Feedback:
When the atopic dermatitis lesions begin to heal, a skin emollient and moisturizer, such
as Eucerin, or baths with a substance to lubricate the skin, such as Alpha-Keri, are
prescribed to prevent excessive skin dryness. The parents should be instructed to soak
the infant in the bath with the lubricant for approximately 15 minutes. The skin should
be patted, not rubbed, dry so lesions are not aggravated. Soap is not to be used for
bathing, because it can be drying. Alcohol dries the skin and can be painful to open
lesions. Hydrocortisone cream may be prescribed to aid in the healing of the lesions.
8. A newborn weighing 6.6 lb is prescribed zidovudine (ZDV) 2 mg/kg every 6 hours to
reduce the risk of maternal transmission of HIV. The pharmacy prepares an infusion of
1,000 mg of the medication in 1 L of 0.9% normal saline. How many milliliters of the
medication will the nurse infuse for each dose? (Numeric value only.)
Ans: 6 ml
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing 6.6 lb
by 2.2 or 6.6 / 2.2 = 3 kg. The nurse then needs to determine the amount of medication
for each dose by multiplying 2 mg × 3 or 6 mg. If the infusion contains 1,000 mg/1,000
ml, then each milliliter contains 1 mg of medication. For a dosage of 6 mg, the nurse
would infuse 6 ml.
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9. The nurse is helping the parents of a toddler identify foods that are causing allergic
symptoms in the child. Which strategy should the nurse encourage the parents to use?
A) Elimination diet
B) Hyposensitivity testing
C) Corticosteroid challenge testing
D) Complete dietary protein restriction
Ans: A
Feedback:
An elimination diet is a traditional method to detect food allergens. Parents feed the
child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet
potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that
are suspected of causing allergy. When a food is introduced this way, the child must be
encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated
from the child's meals on a permanent basis. If no symptoms occur, the child can
continue to eat the food. Hyposensitivity testing is unreliable with food allergies.
Corticosteroids delay hypersensitivity reactions. It is difficulty to totally eliminate
protein from the diet, and this is not a method to determine the cause of food allergies in
the toddler.
10. The nurse is caring for a preschool-age child who has been seen in the emergency
department for an allergic reaction to stinging insects twice in the last month. What
should the nurse instruct the parents to help reduce the child's exposure to insects?
A) Keep the child's hair short.
B) Keep the child away from the trash.
C) Use lightly scented powders and lotions.
D) Avoid going outdoors during the heat of the day.
Ans: B
Feedback:
Children who are allergic to stinging insects should stay away from garbage containers
because insects tend to cluster around trash. The length of hair does not impact the
frequency of insect stings. The parents should avoid scented preparations such as lotions
or powders because these attract insects. The child can go out of doors during the heat
of the day but should not go barefoot and should have a fast-acting insecticide handy to
use on flying insects.
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11. A preschool-age child is being seen for a rash that occurred after the mother applied a
sunscreen prior to permitting the child to swim at the beach. For which type of allergic
reaction should the nurse prepare teaching materials for the mother?
A) Autoimmunity
B) Atopic dermatitis
C) Contact dermatitis
D) Delayed hypersensitivity
Ans: C
Feedback:
Contact dermatitis is an example of a delayed or type IV hypersensitivity response. It is
a reaction to skin contact with an allergen. The allergen causing the irritation is often
suggested by the part of the child's body that is affected. The sunscreen caused the
contact dermatitis in the patient. Autoimmunity is the result of the immune system to
distinguish self from nonself, causing the immune system to carry out immune
responses against normal cells and tissue rather than invading antigens. Individuals with
atopic dermatitis are prone to all types of allergic responses. Three disorders occur most
frequently: hay fever, eczema, and asthma. Delayed hypersensitivity occurs without an
accompanying humoral response. This response causes transplant rejection.
12. The nurse is reviewing the immunization schedule with the mother of a child who has
HIV. What information should the nurse provide the mother about immunizations for
this child? (Select all that apply.)
A) Pneumococcal vaccination can be given.
B) The child should receive live vaccines only.
C) The human papillomavirus vaccine should not be given.
D) The varicella vaccine should not be given if the child is symptomatic.
E) If the CD4 count is low, the measles, mumps, and rubella vaccine should not be
given.
Ans: A, D, E
Feedback:
The nurse should emphasize that live vaccines should not be given to those infected
with HIV. Children should receive routine immunizations according to the usual
schedule with the killed virus vaccines, including pneumococcal and human
papillomavirus vaccine. Symptomatic children should not receive the varicella vaccine,
and those with low CD4 counts should not receive measles, mumps, and rubella (MMR)
vaccine.
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13. The health care provider instructs the parents of a toddler with allergies to avoid
secondary smoke. What teaching should the nurse provide to assist these parents?
(Select all that apply.)
A) Frequent smoke-free establishments.
B) Declare the home and car smoke-free zones.
C) Spray air freshener in the room after smoking.
D) Ask individuals who smoke to smoke out of doors.
E) Encourage family and friends to begin quit-smoking programs.
Ans: A, B, D, E
Feedback:
Guidelines to avoid secondary smoke include frequenting smoke-free establishments,
declaring the home and car smoke-free zones, asking individuals who smoke to smoke
out of doors, and encouraging family and friends to begin quit-smoking programs.
Spraying air freshener in the room after smoking will not reduce the child's exposure to
secondary smoke.
14. Which nursing diagnosis should the nurse use to guide care for a child with allergic
rhinitis?
A) Risk for fluid volume deficit
B) Pain related to sinus edema and headache
C) Ineffective tissue perfusion related to frequent nosebleeds
D) Disturbed self-esteem related to inherited tendency for illness
Ans: B
Feedback:
Children with allergic rhinitis may report full frontal headaches that become even more
marked with adolescence. Pain related to sinus edema and headache would be the most
appropriate diagnosis to guide care for this patient. Allergic rhinitis does not increase
the risk for fluid volume deficit. Nosebleeds are not associated with allergic rhinitis.
Allergic rhinitis is not severe and should not cause disturbed self-esteem.
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15. A child with allergic rhinitis is prescribed a nasal antihistamine spray. When advising
the parents about the use of the sprays, what should the nurse explain about the rebound
phenomenon?
A) It causes a permanent increase in nasal secretions.
B) It causes reflux of gastric contents into the esophagus.
C) It causes an increase in nasal secretions after an initial decrease.
D) It causes a decrease in histamine release after an initial increase.
Ans: C
Feedback:
Review with the parents that if nasal antihistamine sprays are given for more than 3
days, a rebound effect can occur. The nasal mucosa becomes more edematous rather
than less edematous, and symptoms will appear to worsen rather than improve. The
rebound phenomenon does not cause a permanent increase in nasal secretions, reflux of
gastric contents into the esophagus, or a decrease in histamine release after an initial
increase.
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Chapter 43 Nursing Care of a Family When a Child Has an Infectious Disorder
1. The nurse is caring for a 6-month-old child with a rash. Which information from the
parent strongly suggests that roseola is the diagnosis?
A) The rash is a mixture of papules and pustules.
B) The infant is lethargic and not interested in playing.
C) The infant's temperature fell when the rash appeared.
D) The infant's temperature rose at the same time as the rash appeared.
Ans: C
Feedback:
The rash of roseola is distinctive. There are discrete, rose-pink macules approximately 2
to 3 mm in size and flat with the skin surface. With roseola, infants become irritable and
anorexic although even with a high fever remain playful and alert. The condition is
diagnosed based on the physical signs and symptoms with the hallmark being a rash that
appears immediately after a sharp decline in fever.
2. During a health promotion seminar with community members, the nurse provides
information to support the 2020 National Health Goal to prevent and reduce the
incidence of infectious disease in children. What information did the nurse most likely
provide?
A) Participating in age-appropriate exercise
B) Getting adequate rest and sleep each day
C) Importance of maintaining appropriate immunizations
D) Ingesting the recommended amount of fresh fruit and vegetables
Ans: C
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to prevent and
reduce the incidence of infectious disease in children by educating parents about the
importance of immunizations. Rest, sleep, exercise, and dietary intake are not identified
interventions to help achieve the 2020 National Health Goals for infectious disease in
children.
3. The nurse is caring for a school-age child with varicella. What should the nurse observe
about the rash that is associated with this infection?
A) Dark red color
B) Noticeable crusts but no pruritus
C) Dark red, macular, very pruritic lesions
D) Various stages of lesions present at the same time
Ans: D
Feedback:
Most of chickenpox lesions are found on the trunk; although, the face, scalp, palate, and
neck also may be involved. They appear in approximately three separate series or crops,
with each new lesion moving through progressive stages. At some point, all four stages
of lesions—macule, papule, vesicle, and crust—can be present. The lesions are not dark
red in color. These lesions are very itchy.
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4. A school-age child has been placed in airborne precautions until the microorganism
causing the child's symptoms can be identified. Which diagnosis should the nurse
identify as being the most appropriate for the child at this time?
A) Altered body temperature (fever) related to systemic infection
B) Knowledge deficit related to disease prognosis, prevention, and treatment
C) Social isolation related to precautions required to prevent infection transmission
D) Deficient diversional activity related to activity restriction and precautions to
prevent disease transmission
Ans: C
Feedback:
Because the child has been placed in airborne precautions, the diagnosis that is the most
appropriate at this time is social isolation. There is no enough information to determine
if the child is experiencing a fever. The reason for the child's symptoms is not known so
a knowledge deficit is not appropriate at this time. There is also not enough information
to determine if the child has an activity restriction.
5. A school-age child is placed in contact precautions for a communicable disease. Which
observation indicates that teaching about these precautions has been effective?
A) Family members sitting on the patient's bed
B) Father applies a face mask before entering the child's room
C) Mother applies a gown and gloves before entering the child's room
D) Younger brother applies a face mask, gown, gloves, and face shield before
entering the room
Ans: C
Feedback:
For contact precautions, a disposable gown and gloves are required to prevent the
transmission of infection. Family members should not be sitting on the patient's bed. A
face mask and face shield are not required for contact precautions.
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6. The parent of a child with mumps on one side of the face is concerned that the disease
can develop on the other side in the future. What should the nurse respond to the mother
about this concern?
A) The child is immune to further attacks of the disease.
B) It does not matter because mumps in adulthood is not serious.
C) The child should receive active immunization against mumps.
D) There is nothing that can be done to prevent another attack of mumps in the
future.
Ans: A
Feedback:
Some parents worry that because their child had swelling only on one side, the child will
develop mumps on the opposite side in the future. One attack of mumps gives lasting
immunity, and the child will not contract the disease again. Mumps is a potentially
dangerous disease and should not be minimized. The child does not need immunization
against mumps.
7. A group of grade-school children is going camping. Which information should the
school nurse provide to prevent Lyme disease?
A) “Don't approach strange animals outside the campsite.”
B) “Don't touch any bush without knowing what kind it is.”
C) “Don't drink water from mountain streams while hiking.”
D) “Wear jeans tucked inside your socks when in the woods.”
Ans: D
Feedback:
Lyme disease is an infection caused by a tick bite. To prevent the occurrence of tick
bites while camping, the nurse should instruct the children to wear long pants tucked
into the socks while walking in the woods. The risk of rabies is great if approaching
strange animals. Poison ivy or poison oak can be contracted from touching unidentified
bush. Water-based illnesses can be contracted from drinking contaminated water.
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8. The nurse is evaluating outcomes for teaching provided to the mother of a school-age
child with an itchy rash. Which outcome indicates that teaching has been effective?
A) Mother applies hot compresses to itchy skin areas every few hours
B) Child drinks a glass of water every 1 to 2 hours throughout the day
C) Child showers in hot water and uses soap on the rash every morning
D) Child wearing long denim pants and a long-sleeve shirt while playing outside
Ans: B
Feedback:
To relieve the itchiness of a rash, the child should be encouraged to have an adequate
fluid intake to maintain good hydration because dry skin increases discomfort. Cold
cloths or compresses applied to itchy areas are appropriate. Heat makes the itch worse.
Baking soda should be used when bathing in lukewarm water. Hot water and harsh soap
will irritate the rash. The child should be dressed in light cotton clothing so overheating
and perspiration does not occur. Perspiration makes the itch worse. Denim pants and
long-sleeved shirt would make the child very uncomfortable.
9. The nurse is teaching the mother of a 10-month-old baby on the method to administer
nystatin liquid as treatment for thrush. Which technique should the nurse instruct the
mother to use?
A) Administer it immediately after meals.
B) Give it just prior to meals for best absorption.
C) Give it mixed with orange juice to disguise the taste.
D) Administer it mixed with milk to decrease stomach irritation.
Ans: A
Feedback:
Nystatin is an effective antifungal drug for oral thrush. The medication should be
dropped into the mouth after feedings so it will remain in contact with the lesions rather
than being washed away immediately by a feeding. The medication should not be given
before meals or mixed with orange juice or milk.
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10. The home care nurse is observing a mother prepare mupirocin (Bactroban) to treat a
preschool-aged child's skin rash. At which point should the nurse stop the mother during
the preparation of the medication?
A) Mother washes the lesions before using the medication.
B) Mother washes own hands after touching the child's rash.
C) Mother is still using the medication on day 9 of the infection.
D) Mother measures out a teaspoon of the medication for the child to take orally.
Ans: D
Feedback:
Mupirocin (Bactroban) is a topical antibiotic and should not be taken orally. The mother
should wash the lesions before applying the medication. The mother should wash the
hands before and after applying the medication or touching the rash. The mother should
use the medication for the full course even though the rash and lesions might appear
healed.
11. Which intervention would be the most important for the nurse to include in the plan of
care for a child with infectious mononucleosis?
A) Limiting fluid intake
B) Moving the child carefully
C) Administering a corticosteroid
D) Counseling the child to stop kissing
Ans: B
Feedback:
Be careful in helping children with mononucleosis to turn in bed ensuring that no
pressure is placed over the splenic area. If palpating the spleen, do so gently to avoid
inadvertent rupture. The child needs an adequate fluid intake. Corticosteroids are not
indicated for this disease. Counseling on the transmission of the illness can occur later
when the child's health improves.
12. An infant is diagnosed with streptococcal-based impetigo. What should the nurse teach
the mother about the infant's care?
A) Help avoid thumb-sucking.
B) Change the dressings every day.
C) Provide penicillin as prescribed.
D) Administer the steroid as prescribed.
Ans: C
Feedback:
Treatment of impetigo is oral administration of penicillin for 7 to 10 days.
Thumb-sucking is not a cause for this disease. The lesions of impetigo are not covered
with dressings. Steroids are not used to treat this disease.
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13. A toddler is being treated for pinworms. What advice should the nurse give to the
mother to prevent reinfection?
A) Help the child wash hands before eating.
B) Don't allow the child to play on the floor.
C) Urge the child to void as frequently as possible.
D) Don't allow the child to play with the family dog.
Ans: A
Feedback:
Pinworms are small, white, threadlike worms that live in the cecum and are transmitted
to the mouth. Children should be taught to wash the hands before eating to prevent the
transmission of the worms back into the digestive tract. Playing on the floor, frequent
voiding, and playing with the dog will not help prevent reinfection with pinworms.
14. A school-age child with a rash over the abdomen now has a bright red tongue. The
health care provider is going to begin treatment for scarlet fever. On which medication
should the nurse instruct the mother for the child's care?
A) Aspirin
B) Steroids
C) Antibiotics
D) Antifungal medication
Ans: C
Feedback:
Because the underlying reason for scarlet fever is a streptococcal infection, a course of
antibiotics will be prescribed. Aspirin is not usually provided to children for fever
control. Steroids are not used to treat scarlet fever. The child's red tongue is not because
of an oral fungal infection.
15. During a routine assessment, the nurse determines that a school-age child has head lice.
What did the nurse assess in this child?
A) Macular rash on the arms
B) White flecks on hair shafts
C) Red raised rash on the neck
D) Pustule formation on the trunk
Ans: B
Feedback:
Pediculosis capitis or head lice are characterized by small, white flecks on hair shaft,
which are nits or the eggs of lice, and extreme pruritus. Head lice are not associated with
a macular rash, a red raised rash, or pustule formation.
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Chapter 44 Nursing Care of a Family When a Child Has a Hematologic Disorder
1. The nurse has been asked to participate in a community health teaching session. Which
interventions should the nurse include to help achieve the 2020 National Health Goals to
reduce the incidence of anemias? (Select all that apply.)
A) Explain the importance of healthy eating for adolescent participants.
B) Instruct pregnant women to take iron supplementation as prescribed.
C) Emphasize ways to reduce unintentional injuries at home, work, and play.
D) Review foods that are rich in iron that should be a part of school-age children's
diets.
E) Examine strategies for elderly community members to improve the quality of life.
Ans: A, B, D
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to improve
children's health and reduce hospitalization from anemia by educating parents about the
importance of women taking an iron supplement during pregnancy, encouraging
iron-rich food sources for young children, and educating adolescents about healthy
diets. Prevention of unintentional injuries and improving the quality of life for the
elderly are not interventions to achieve this National Health Goal.
2. The nurse is concerned that a school-age child has iron-deficiency anemia. What did the
nurse assess in this patient?
A) Shyness
B) Thumb-sucking
C) Asks many questions
D) Craving for ice cubes
Ans: D
Feedback:
In school-age children, there is an association between iron-deficiency anemia and pica
or the craving for ice cubes. Iron-deficiency anemia is not associated with shyness,
thumb-sucking, or inquisitive behavior.
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3. The nurse is evaluating the effectiveness of teaching provided to the parents of a
school-age child prescribed liquid ferrous sulfate (Feosol) for iron-deficiency anemia.
Which observations indicate that teaching has been effective? (Select all that apply.)
A) Mother places medication in orange juice.
B) Mother provides medication with a glass of milk.
C) Child observed consuming fresh raw fruit and drinking water.
D) Mother provides liquid-prepared medication to the child with a straw.
E) Child goes to the bathroom to brush teeth immediately after taking the
medication.
Ans: A, C, D, E
Feedback:
The liquid preparation of ferrous sulfate (Feosol) should be mixed with juice and
swallowed by using a straw to avoid teeth staining. The child should thoroughly brush
teeth to also prevent staining. High-fiber foods and water help reduce the risk of
constipation from this medication. This medication should not be taken with milk
because it will interfere with absorption.
4. A school-age child weighing 55 lb is prescribed to receive 15 ml/kg of packed red blood
cells. If the child is to receive 10 ml/kg/hr, how many hours will it take to infuse the
prescribed amount of blood for this patient? (Calculate to the nearest 10th decimal
point.)
Ans: 1.5 hours
Feedback:
The child weighs 55 lb. To determine weight in kilogram, divide 55 lb by 2.2 = 25 kg.
Then multiply the weight in kg by 15 ml to determine the total amount of blood the
patient is to receive or 15 ml × 25 kg = 375 ml. Then to determine the amount of blood
to infuse per hour, multiply 10 ml × 25 kg = 10 × 25 = 250 ml. If the child is to receive a
total of 375 ml of blood, divide 375 ml by 250 ml to determine that the prescribed
amount of blood will take 1.5 hours to infuse.
5. A school-age child is scheduled for a bone marrow aspiration to confirm the diagnosis
of aplastic anemia. What should the nurse instruct the child about this procedure?
A) Leg pain will occur after the procedure.
B) It will be done under general anesthesia.
C) A narrow needle is used so there is no pain.
D) The patient will have to lie on the stomach for the procedure.
Ans: D
Feedback:
The child is to lie on prone on a hard surface for the procedure. Leg pain is not expected
after the procedure. Conscious sedation and not general anesthesia is used for the
procedure. This is a painful procedure, and topical anesthesia is applied in addition to
conscious sedation to help reduce the pain.
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6. It is determined that a preschool-age child developed anemia after exposure to an
insecticide. What should the nurse teach the parents before the child is discharged from
the hospital?
A) Schedule weekly chelating treatments.
B) Provide the child with a high-protein diet.
C) Schedule hospital visits to desensitize the child to the insecticide.
D) Ensure that the child has no further exposure exposed to the insecticide.
Ans: D
Feedback:
The first step in therapy is to immediately ensure that the child is never exposed to the
substance again. Chelation therapy is to remove excess iron from the blood and body. A
high-protein diet is not indicated for this health problem. The child does not need
weekly hospital visits for desensitization.
7. A toddler weighing 22 lb with hemophilia A fell down several steps and sustained a
knee injury. The parents have been instructed to provide the child with an infusion of
factor VIII concentrate, one bag per 5 kg of body weight. How many bags of the
concentrate will the parents infuse into the child? (Calculate to the nearest tenth decimal
point.)
Ans: 2 bags
Feedback:
First, determine the child's weight in kilogram by dividing 22 lb by 2.2 = 10 kg. If the
parents are to infuse one bag of concentrate for every 5 kg of body weight then divide
the total body weight by 5 or 10 kg/5 = 2. The child is to receive 2 bags of factor VIII to
treat this injury.
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8. The nurse is caring for a school-age child recovering from an allogeneic stem cell
transplant. What should the nurse do to ensure the child does not develop an infection
after the transplant? (Select all that apply.)
A) Restrict all visits from other children.
B) Provide sterilized age-appropriate play materials.
C) Send for total body irradiation immediately after the transplant.
D) Make arrangements for schoolwork to be delivered to the hospital.
E) Encourage eating raw vegetables for each meal after the procedure.
Ans: A, B
Feedback:
To prevent the child from contracting an infection until the WBC count returns to a safe
range, the child is restricted from interacting with other children either by remaining in
the hospital or employing visiting restrictions at home. The nurse should provide
sterilized play materials the child would enjoy as appropriate. Total body irradiation is
completed before the transplant and not after. Schoolwork will not reduce the child's
risk of developing an infection after the transplant. The only raw fruits that are
permitted are those with thick skin such as bananas and oranges. Other raw fruits and
vegetables are avoided because these foods can carry bacteria.
9. A child with hypoplastic anemia develops hemosiderosis. What should the nurse prepare
to instruct the parents about the treatment for this disorder?
A) Need to avoid all products containing aspirin
B) Need to infuse deferoxamine (Desferal) at home
C) Importance of daily doses of ferrous sulfate (Feosol)
D) Importance of adhering to a strict schedule of prednisone
Ans: B
Feedback:
Treatment of anemia is through transfusion of packed red blood cells to increase
erythrocyte levels. As a result of the necessary number of transfusions, hemosiderosis or
the deposition of iron in body tissue can occur. Treatment for hemosiderosis is iron
chelation through the use of subcutaneous infusions of deferoxamine (Desferal). These
infusions are to be given at home overnight for 5 to 6 nights per week. There is no
enough information to determine if aspirin should be avoided. Ferrous sulfate (Feosol)
will add more iron to the patient's body and should be avoided. Children with congenital
hypoplastic anemia may receive corticosteroid therapy along with transfusions of
packed RBCs to raise erythrocyte levels.
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10. The nurse is assessing a school-age child with sickle-cell anemia. Which assessment
finding is consistent with this patient's diagnosis?
A) Slightly yellow sclera
B) Enlarged mandibular growth
C) Increased growth of long bones
D) Depigmented areas on the abdomen
Ans: A
Feedback:
In sickle-cell anemia, eye scleras become icteric or yellowed from the release of
bilirubin from the destruction of the sickled cells. Mandibular and long bone growth and
depigmentation are not manifestations of this health problem.
11. An 18-month-old child is diagnosed with insufficient platelets. What should the nurse
instruct the parents to reduce the risk of the child bleeding when at home? (Select all
that apply.)
A) Check that all toys have soft corners.
B) Engage in limited amounts of rough play each day.
C) Ensure mouth care is performed with a soft toothbrush.
D) Do not apply Band-Aids or adhesive tape onto the skin.
E) Pad the side and crib rails on the bed at home to prevent bruising.
Ans: A, C, D, E
Feedback:
To prevent bleeding in the child with insufficient platelets, the nurse should instruct the
parents to check that all toys have soft corners so no skin scratches occur. Mouth care
should only be done with a soft toothbrush so that gum excoriation does not occur. No
adhesives should be applied to the skin because the skin can tear during the removal of
these items. The bed and crib rails should be padded to ensure the child does not
become bruised while sleeping. All rough play is to be avoided because this can lead to
an accidental injury and subsequent bleeding.
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12. The nurse is instructing the parents of a child with sickle-cell anemia on safety
precautions. What should the nurse emphasize during this teaching?
A) Suggest the child participate in sports activities without restriction.
B) Treat upper respiratory infections with over-the-counter medication.
C) Ensure a consistent and daily intake of adequate fluids to prevent dehydration.
D) Remind to avoid immunizations to prevent the introduction of bacteria into the
body.
Ans: C
Feedback:
Safety interventions for the child with sickle-cell anemia include ensuring an adequate
daily intake of fluids to prevent dehydration. Dehydration will precipitate a crisis, which
can be avoided. The child should avoid contact sports and long-distance running. Upper
respiratory infections should be reported to the health care provider so appropriate
treatment can be provided. Routine health care such as immunizations should be
provided in order to prevent common childhood illnesses.
13. While receiving a transfusion of packed red blood cells, a school-age child begins to
experience itchy skin, hives, and wheezes. What should the nurse do first for this child?
A) Stop the transfusion.
B) Obtain a blood culture.
C) Slow the transfusion rate.
D) Provide a diuretic as prescribed.
Ans: A
Feedback:
Itchy skin, hives, and wheezes while receiving a blood transfusion indicate an allergic
reaction to the blood proteins. The nurse should stop the infusion. This will be
temporary because after the child receives oxygen and an antihistamine, the transfusion
will be resumed. Blood cultures are indicated if the child experiences an increase in
body temperature. Slowing the transfusion rate will not reduce the patient's symptoms.
A diuretic would be indicated if the child demonstrates shortness of breath and an
increased pulse rate.
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14. Which nursing diagnosis should the nurse identify as being the most appropriate for a
child with idiopathic thrombocytopenic purpura?
A) Risk for infection related to abnormal immune system
B) Risk for bleeding related to insufficient platelet formation
C) Risk for altered urinary elimination related to kidney impairment
D) Ineffective breathing pattern related to decreased white blood count
Ans: B
Feedback:
Idiopathic thrombocytopenic purpura (ITP) is the result of a decrease in the number of
circulating platelets in the presence of adequate megakaryocytes, which are precursors
to platelets. Because bleeding can occur with this disease process, the diagnosis most
appropriate for the patient at this time is risk for bleeding related to insufficient platelet
formation. Reduced numbers of platelets would not increase the patient's risk for
infection. Reduced numbers of platelets does not increase the patient's risk for renal
impairment. Reduced risk of platelets will not lead to an ineffective breathing pattern.
15. The nurse is planning care for a school-age child recovering from being hit by a motor
vehicle while riding a bicycle home from school. For what will the nurse assess to
determine the onset of disseminated intravascular coagulation in this child?
A) Blurred vision
B) Nausea and vomiting
C) Sudden onset of knee pain
D) Bleeding from intravenous sites
Ans: D
Feedback:
Disseminated intravascular coagulation is an acquired disorder of blood clotting that
result from excessive trauma. The child begins to develop petechiae or have
uncontrolled bleeding from puncture sites from injections or intravenous therapy.
Blurred vision, nausea, vomiting, and a sudden onset of knee pain are not manifestations
associated with disseminated intravascular coagulation.
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Chapter 45 Nursing Care of a Family When a Child Has a Gastrointestinal Disorder
1. The nurse is working with a school district to ensure students do not develop food-borne
illnesses. Which intervention should the nurse emphasize that supports the 2020
National Health Goals regarding food preparation?
A) Refrigerate foods promptly.
B) Provide fresh fruits and vegetables.
C) Ensure all students are appropriately immunized.
D) Examine the number of students who contract food-borne illnesses.
Ans: A
Feedback:
Unsafe food preparation is an area that could be reduced in incidence if people knew
more about it and took active interventions to reduce its occurrence or spread. The 2020
National Health Goals addressing these include reducing infections caused by key
pathogens transmitted commonly through food and increasing the proportion of
consumers who follow key food safety practices of “Chill: refrigerate promptly.” Nurses
can help the nation achieve the goal by counseling parents about safe food preparation
and serving as consultants to those responsible for food preparation.
2. The nurse is caring for an infant recovering from surgery for pyloric stenosis. Which
nursing diagnosis should the nurse use to guide care during the immediate postoperative
period?
A) Anxiety related to new feeding method used postoperatively
B) Ineffective tissue perfusion related to pressure on heart chambers
C) Excess fluid volume related to increased fluid intake prescribed postoperatively
D) Risk for infection of incision line, related to disruption of skin barrier during
surgery
Ans: D
Feedback:
Because the incision line for a pyloric stenosis repair is near the diaper area, the child is
at risk for developing a surgical infection. The diagnosis risk for infection of incision
line is the most appropriate during the immediate postoperative period. Anxiety might
be appropriate after the immediate postoperative period has passed. There is no enough
information to determine if the infant is being given excessive fluid or if the infant is
experiencing ineffective tissue perfusion.
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3. The mother of a 3-month-old infant is distraught because the child vomits after every
feeding. After an assessment, the nurse determines that the infant is experiencing
regurgitation and not vomiting. What did the nurse assess in the infant? (Select all that
apply.)
A) Slight sour smell
B) Occurs after a feeding
C) Accompanied by prolonged crying
D) Runs out of the mouth with no force
E) Volume amount similar to entire stomach contents
Ans: A, B, D
Feedback:
Evidence of regurgitation includes a slightly sour smell to the emesis, occurs after a
feeding, and runs out of the mouth without any force. Evidence of vomiting would be
infant distress by prolonged crying and a large volume similar to that of entire stomach
contents.
4. A preschool-age child has been experiencing severe vomiting for over 24 hours. The
child's respiratory rate is currently 10 breaths/min. On which health problem will the
nurse focus when caring for this child?
A) Overhydration
B) Metabolic acidosis
C) Metabolic alkalosis
D) Hypertonic dehydration
Ans: C
Feedback:
With vomiting, a great deal of hydrochloric acid is lost. When Cl– ions are lost this way,
the body has to decrease the number of H+ ions present so the number of positive and
negative charges remains balanced. This causes the child to develop alkalosis. The lungs
attempt to conserve carbon dioxide and water by slowing respirations. Overhydration
generally occurs in children who are receiving IV fluid, ingestion of large quantities of
tap water, or through the use of tap water enemas. Metabolic acidosis is more closely
associated with diarrhea. Hypertonic dehydration occurs when water is lost in a greater
proportion than electrolytes. This might occur in a child with nausea, fever, and profuse
diarrhea.
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5. A 1-month-old infant is diagnosed with gastroesophageal reflux. Which intervention
should the nurse teach the mother to help with the symptoms of this disorder?
A) Hold in a horizontal position while feeding.
B) Place on the back immediately after feeding.
C) Feed with formula thickened with rice cereal.
D) Administer prescribed medications before each feeding.
Ans: C
Feedback:
The traditional treatment of gastroesophageal reflux is to feed infants a formula
thickened with rice cereal. The baby should be held in an upright position and then kept
upright in an infant chair for 1 hour after feeding so gravity can help prevent reflux.
Medication for gastroesophageal reflux is prescribed daily and not before each feeding.
6. A 2-month-old infant experiencing severe diarrhea is prescribed intravenous fluid
replacement. Before adding potassium to this solution, which assessment should the
nurse make?
A) Is voiding
B) Is sleeping
C) Is crying with tears
D) Hands are restrained
Ans: A
Feedback:
Although infants usually have a potassium depletion, potassium is not given until it is
established the child is not in renal failure because giving potassium IV when the body
has no outlet for excessive potassium can lead to excessively high potassium levels and
heart block. Before this initial IV fluid is changed to a potassium solution, the nurse
needs to be certain that the infant has voided, which is proof that the kidneys are
functioning. The nurse does not need to ensure that the child is sleeping, crying with
tears, or has the hands restrained.
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7. During the assessment of a preschool-age child, the nurse notes that the child's tongue is
tender and there are cracks in the corners of the child's mouth. Which vitamin deficiency
does the nurse suspect this child is experiencing?
A) Vitamin A
B) Vitamin B1
C) Vitamin C
D) Vitamin D
Ans: A
Feedback:
A vitamin A deficiency is caused by a lack of yellow vegetables in the diet.
Manifestations of this deficiency include a tender tongue and cracks at the corners of the
mouth. Manifestations of a vitamin B1 deficiency include beriberi, diarrhea, and
vomiting. Manifestations of a vitamin C deficiency include muscle tenderness and
petechiae. Manifestations of a vitamin D deficiency include poor muscle tone, delayed
tooth formation, poor bone formation, swelling of the wrists and cartilage of ribs, bowed
legs, and muscle spasms.
8. The nurse is advising a group of new parents on how to care for their infant at home if
the baby develops mild diarrhea. Which statement indicates that teaching has been
effective?
A) “I should offer milk after each episode of diarrhea.”
B) “I should take the baby's temperature and call my physician.”
C) “I could give Kaopectate as long as I follow the directions on the bottle.”
D) “I should offer Pedialyte after 1 hour and frequently thereafter to prevent
dehydration.”
Ans: D
Feedback:
Mild diarrhea is not considered serious and at the end of approximately 1 hour, parents
can begin to offer an oral rehydration solution such as Pedialyte in small amounts.
Infants may develop a temporary lactase deficiency after diarrhea that leads to lactose
intolerance. With this, a child cannot take formula or breast milk without new diarrhea
beginning. Parents should alert their health care provider if they feel this is happening as
the infant will need to be introduced to a lactose-free formula initially before being
returned to the usual formula or to breast milk. An elevated temperature is seen in
severe diarrhea. The parents should be cautioned to contact their health care provider
prior to initiating over-the-counter drugs such as kaolin and pectin (Kaopectate) to halt
diarrhea because toxic levels of these can occur quickly.
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9. The nurse suspects that an infant is experiencing intussusception. What did the nurse
assess in this infant? (Select all that apply.)
A) Crying as if in severe pain
B) Pulse rate of 78 beats/min and irregular
C) Sudden drawing up of the legs
D) Vomit that looks like currant jelly
E) Leg drawing up and crying repeats every 15 minutes
Ans: A, C, D, E
Feedback:
With intussusception, the infant will suddenly draw up the legs and cry as if in severe
pain. After the peristaltic wave that caused the discomfort passes, the infant is symptom
free but in approximately 15 minutes the same pattern repeats. After approximately 12
hours, blood can appear in the vomitus and looks like “currant jelly.” A slow pulse rate
is not typically assessed in an infant with intussusception.
10. A school-aged child with Crohn's disease will receive enteral nutrition for the next 6
weeks. What should the nurse counsel the parents to do to support this child's needs?
A) Provide the feeding during regular meal times.
B) Encourage the child to stay with the family during routine meal times.
C) Suggest the child stay in the bedroom during routine meal times with the family.
D) Explain that this might be a permanent method to have nutrition going forward.
Ans: B
Feedback:
When nutrition is supplied by enteral solutions, the enteral infusion should be provided
during the night. Removing the tube during the day can make feedings more tolerable.
Meal time provides social stimulation so the parents should encourage the child to spend
time with the family during routine meal times. The feedings should not be provided
during regular meal times. Having the child stay in the bedroom during meal times with
the family will not support the child's socialization needs. There is no way of knowing if
enteral feedings will be a permanent method for this child to obtain nutrition going
forward.
11. An adolescent patient is diagnosed with hepatitis A. Which problem should the nurse
consider when planning the care for this patient?
A) The patient will develop hypothermia.
B) The patient will become easily fatigued.
C) The patient's urine will be dark and infectious.
D) The patient will be very irritable and perhaps require sedation.
Ans: B
Feedback:
The treatment for hepatitis A is increased rest because of fatigue. Hypothermia is not
associated with hepatitis A. Dark infectious urine is not associated with this disease
process. The patient will not be irritable and will not need sedation.
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12. A 14-year-old child is brought into the emergency room with manifestations consistent
with a ruptured appendix. What is the first action that the nurse should take in the care
of this child?
A) Apply oxygen.
B) Position flat in bed.
C) Place in the semi-Fowler's position.
D) Insert an indwelling urinary catheter.
Ans: C
Feedback:
If a child's appendix has already ruptured when the child is seen in the emergency
department, the potential for peritonitis increases greatly. The child should be positioned
in a semi-Fowler's position so that infected drainage from the cecum drains downward
into the pelvis rather than upward toward the lungs. Oxygen is not indicated for this
disorder. Positioning flat in bed could cause draining to move toward the lungs. An
indwelling urinary catheter is not indicated for this disorder.
13. The nurse is evaluating teaching provided to the mother of a child with celiac disease.
Which type of breakfast indicates that instruction has been effective?
A) Eggs and orange juice
B) Oat cereal and skim milk
C) Wheat toast and grape jelly
D) Rye toast and peanut butter
Ans: A
Feedback:
Parents need a great deal of nutritional counseling when their child is first placed on a
gluten-free diet so they can recognize foods that contain gluten, which include wheat,
rye, oats, and barley products. Eggs and orange juice is the only breakfast that does not
contain wheat, rye, or oats. The oat cereal contains oats. Wheat toast contains wheat.
Rye toast contains rye.
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Chapter 46 Nursing Care of a Family When a Child Has a Renal or Urinary
Tract Disorder
1. A female preschool patient with a urinary tract infection is scheduled to have a voiding
cystourethrogram. What should the nurse include when teaching the patient about this
procedure?
A) A headache is a common occurrence after the procedure.
B) A local anesthetic will be injected prior to the procedure.
C) The patient will be expected to void during the procedure.
D) The patient will have to drink three glasses of water during the procedure.
Ans: C
Feedback:
A voiding cystourethrogram is a study of the lower urinary tract and looks at the
structure of the urethra and bladder and the presence of reflux into the ureters. After
bladder catheterization, a radiopaque dye is injected into the bladder, and the catheter is
then removed. The child is asked to void into a bedpan while serial X-ray films are
taken. Being asked to void while being observed may be the most stressful part of the
procedure for children because they have been taught voiding is a private act. Be sure
children are told in advance that they will be asked to do this, and that it is alright if a
stranger watches them. A headache is not a common occurrence after this procedure. A
local anesthetic is not needed for this procedure. The patient will not be asked to drink
water during the procedure.
2. The nurse is caring for a female preschool-age patient with a urinary tract infection.
What measures should the nurse teach the mother to prevent future infections?
A) Suggest the child drink less fluid daily to concentrate urine.
B) Encourage the child to be more active to increase urine output.
C) Teach the child to wipe the perineum front to back after voiding.
D) Teach the child to take frequent tub baths to clean the perineal area.
Ans: C
Feedback:
Urinary tract infections occur more often in girls than boys because the urethra is shorter
in girls and, because it is located close to the vagina and anus, vulvovaginitis or rectal
bacteria can easily spread to the urethra. Girls should be taught early to wipe themselves
from front to back after voiding and defecating to avoid contaminating the urethra. The
child should be encouraged to drink more fluid to prevent concentrated urine. Activity
level does not influence the development of urinary tract infections. There is a suggested
correlation between the use of hot tubs and urinary tract infections in girls so use of
these should be discouraged or minimized.
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3. The nurse is planning a community health program to improve awareness of renal
disease as one of the 2020 National Health Goals. What information should the nurse
include in this program? (Select all that apply.)
A) Instruct on organ transplantation procedures.
B) Explain the importance of restricting fluids after 6 PM.
C) Review recommended foods to promote renal functioning.
D) Teach to limit the intake of milk and dairy products with meals.
E) Remind parents to provide antibiotics for streptococcal throat infections.
Ans: A, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for renal disease by
educating parents to give antibiotics conscientiously for streptococcal throat infections
and being active advocates for organ transplant procedures. Restricting fluids,
recommending specific foods, and limiting the intake of milk and dairy products are not
interventions to support the 2020 National Health Goals for renal disease.
4. The nurse is providing a child with oxybutynin (Ditropan) as prescribed following
surgical repair of a hypospadias. What should the nurse teach the patient about the
purpose of this medication?
A) Acidifies urine
B) Relieves bladder spasms
C) Stimulates kidney function
D) Prevents nausea and vomiting
Ans: B
Feedback:
The child may notice painful bladder spasms as long as the catheter is in place after
surgical repair of a hypospadias. An anticholinergic medication, which relieves bladders
spasms such as oxybutynin (Ditropan), may be prescribed for pain relief. Oxybutynin
(Ditropan) does not acidify the urine, stimulate kidney function, or prevent nausea and
vomiting.
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5. The nurse instructs a school-age patient and the parents on continuous cycling peritoneal
dialysis. Which statement indicates that teaching has been effective?
A) “The solution should be infused cold.”
B) “Redness and warmth around the tube insertion site is expected.”
C) “We should notify the health care provider if the drainage is cloudy.”
D) “Weight gain and a productive cough are expected with the treatments.”
Ans: C
Feedback:
Cloudy drainage could indicate an infection such as peritonitis and should be reported to
the health care provider. The solution should be infused at body temperature. Redness
and warmth around the tube insertion site could indicate an infection and should be
reported to the health care provider. Weight gain and a productive cough could indicate
fluid retention and should be reported to the health care provider.
6. The parents of child recovering from surgery to repair vesicoureteral reflux ask the
nurse if they can do anything to help with the care of their child. What should the nurse
encourage the parents to do at this time?
A) Help the child with a tub bath.
B) Bring in games and other diversions to keep the child distracted while on bed rest.
C) Assist the child out of bed while keeping the drainage bags below the level of the
catheter.
D) Provide hard candy to help with mouth dryness because the child will be on a
fluid restriction.
Ans: C
Feedback:
Be sure that the child and parents understand the importance of not raising the collection
system above the child's bladder level when helping the child out of bed. This helps
prevent potentially contaminated urine from flowing from the tubes back into the
bladder or ureters. Tub baths are contraindicated until all surgical sites have healed. The
child will not be on bed rest so diversional activities are not needed. The child will not
be on a fluid restriction so hard candy is not needed to help with mouth dryness.
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7. The nurse is teaching manifestations of nephrotic syndrome to the parents of a child
with the disorder. What should the nurse instruct the parents to monitor to determine if
edema is increasing?
A) Appetite
B) Breathing rate
C) Tightness of shoes
D) Abdominal circumference
Ans: D
Feedback:
Edema tends to be dependent or occur in the lower parts of the body. Parents may notice
clothing no longer fits a child around the waist because edematous fluid is beginning to
collect in the abdominal cavity or ascites. This is what the parents should monitor in the
child. Appetite and breathing rate will be affected later after a significant amount of
ascites fluid accumulates. Edema in the feet is not a typical manifestation of this
disorder.
8. A school-age child is returning home after a renal biopsy. What teaching should the
nurse provide to the patient and parents at this time? (Select all that apply.)
A) Remove the dressing in 2 hours.
B) Resume regular activity level at home.
C) Drink a glass of fluid every hour while awake.
D) Expect the first voided urine to be blood-tinged.
E) Teach how to keep serial urine samples for 24 hours.
Ans: C, D, E
Feedback:
If a renal biopsy is done on an ambulatory basis, children can be discharged 2 to 4 hours
after the procedure if vital signs are stable and they have voided. Encourage children to
drink a glass of fluid every hour while awake during the first 24 hours to keep urine
flowing freely and prevent blood from clotting in the kidney tubules and blocking urine
flow. The first voiding after renal biopsy is invariably blood-tinged. Instruct parents
how to keep serial urine samples, comparing each specimen with the previous one, to
detect whether hematuria is becoming more or less marked. The dressing should not be
disturbed. Parents should keep the child on restricted activity for 24 hours or until no
more hematuria is present.
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9. The parents of a child with acute glomerulonephritis ask the nurse to explain the cause
of the disease. What organism should the nurse instruct the parents as being the cause
for the disorder?
A) Group B streptococci
B) One of the rhinoviruses
C) Staphylococcus viridans
D) Group A beta-hemolytic streptococci
Ans: D
Feedback:
Glomerulonephritis usually occurs in children as an immune complex disease after
infection with group A beta-hemolytic streptococci. Acute glomerulonephritis is not
caused by group B streptococci, rhinoviruses, or Staphylococcus viridans.
10. The nurse is teaching the parent of a child with chronic renal failure on high-potassium
foods that should be restricted. Which foods will the nurse include in this teaching?
(Select all that apply.)
A) Bananas, carrots, nuts, and milk
B) Peaches, broccoli, and red meat
C) Oranges, potatoes, wheat, and bran
D) Spinach, chicken, fish, and green beans
Ans: A
Feedback:
Foods that are high in potassium include bananas, carrots, nuts, and milk. Broccoli,
wheat, bran, chicken, fish, and green beans are not high in potassium and do not need to
be restricted.
11. The nurse is prescribed to infuse 75 ml/kg of dialysate for a child's peritoneal dialysis
treatment. The child weighs 77 lb. At the conclusion of the treatment, the nurse
measures 3,000 ml of dialysate outflow. How much of the outflow should the nurse
document as peritoneal fluid?
Ans: 375 ml
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing 77 lb by
2.2 or 77 / 2.2 = 35. Then the nurse should multiply the prescribed volume of dialysate
by the patient's weight in kilograms or 75 ml × 35 = 2,625 ml. This is the volume that
the nurse will provide for the dialysate inflow. Next, the nurse needs to subtract the total
inflow volume from the outflow volume or 3,000 ml – 2,625 ml = 375 ml. This is the
volume of peritoneal fluid that the nurse should document.
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12. The nurse is caring for a child experiencing hyperkalemia from renal failure. What
should the nurse prepare to administer to this patient?
A) Milk
B) Fruit juice
C) Glucose and insulin
D) Sodium and increased fluid
Ans: C
Feedback:
Administration of intravenous glucose and insulin helps to remove excess potassium.
The insulin helps the glucose move into the cells, and potassium moves along with it.
Intravenous calcium gluconate, and not milk, can also be used to remove excess
potassium. Fruit juice has no effect on potassium level and might cause it to increase.
Sodium bicarbonate, and not sodium, and increased fluid also help to remove excess
potassium.
13. A child with chronic renal failure does not want to take the prescribed aluminum
hydroxide gel because of the taste. What should the nurse tell the patient about the
purpose of this medication?
A) Prevents an upset stomach
B) Assists with the absorption of calcium
C) Assists with elimination of potassium
D) Reduces absorption of phosphorus from the GI tract
Ans: D
Feedback:
Children with chronic renal failure are generally placed on a diet to prevent rapid urea
and phosphate buildup. Children may be prescribed aluminum hydroxide gel to take
with meals to bind phosphorus in the intestines and prevent absorption of phosphorus
from foods. This medication is not being given to the patient to prevent an upset
stomach. This medication does not assist with the absorption of calcium or the
elimination of potassium.
14. The nurse is concerned that a school-age child receiving intranasal desmopressin acetate
(DDAVP) for enuresis is experiencing an adverse effect of the medication. What did the
nurse assess in this patient? (Select all that apply.)
A) Thirst
B) Nausea
C) Flushing
D) Itchy skin
E) Headache
Ans: B, C, E
Feedback:
Adverse effects of desmopressin acetate (DDAVP) include nausea, flushing, and a
headache. Thirst and itchy skin are not identified as adverse effects of this medication.
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15. The nurse is caring for a child recovering from a kidney transplant. Which nursing
diagnosis should the nurse identify as the priority to guide the care for this patient?
A) Pain related to tissue rejection
B) Constipation related to effects of administered drugs
C) Risk for infection related to immunocompromised state
D) Deficient fluid volume related to fluid intake restrictions postoperatively
Ans: C
Feedback:
After renal transplantation, children are cared for in an environment that is as sterile as
possible as they are placed on immunosuppressive therapy to reduce the possibility of
kidney rejection. Immunosuppressive therapy increases the patient's risk of developing
an infection. The priority nursing diagnosis at this time is the risk for infection. Tissue
rejection would not be immediate. The patient's pain would be from the surgical site.
There is no information to support that the patient's medication will cause constipation.
It is unlikely that the patient will be on a fluid restriction after surgery since there is a
need to evaluate the functioning of the transplanted kidney.
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Chapter 47 Nursing Care of a Family When a Child Has a Reproductive Disorder
1. A preschool-age child recovering from a surgery to correct undescended testes
expresses fear about having a “body part cut off.” Which nursing diagnosis should the
nurse use to guide care while addressing this child's concern?
A) Risk for insufficient fluid balance
B) Ineffective coping related to altered physical appearance
C) Disturbed body image related to change in physical appearance
D) Deficient knowledge related to child's inexperience with surgical procedure
Ans: C
Feedback:
The postoperative evaluation after surgery to correct undescended testes should address
the boy's feelings about the surgery and the changes in his body. He may need an
opportunity to express his fears about mutilation or castration by playing with puppets
or dolls after surgery. This surgery is not associated with fluid balance. The child will
not have an altered physical appearance after the surgery. The child's fear is more than a
knowledge deficit about the surgical procedure.
2. The nurse reviews the 2020 National Health Goals for sexual health prior to preparing a
presentation for high school students. On what should the nurse focus when preparing
this teaching for the students?
A) Prevention of sexually transmitted infections
B) Communicating health needs to the primary care physician
C) Importance of staying current with recommended immunizations
D) Creating a work–life balance between school and extracurricular activities
Ans: A
Feedback:
The 2020 National Health Goals for sexual health focus on the prevention and early
treatment of sexually transmitted infections. This is the topic in which the nurse should
focus during the presentation with adolescent students. The 2020 National Health Goals
for sexual health do not address communication with primary care physicians,
immunizations, or creating a work–life balance.
3. A baby is born with ambiguous genitalia. What should the nurse emphasize when
discussing this with the parents?
A) Ambiguous genitalia result from hypothalamus stimulation.
B) The child's true sex can be determined by a genetic karyotype.
C) Ambiguous genitalia will develop fully with estrogen therapy.
D) All children with ambiguous genitalia are chromosomally female.
Ans: B
Feedback:
If there is any question about a child's gender, karyotyping or DNA analysis establishes
whether the child is genetically male or female. Ambiguous genitalia do not result from
hypothalamus stimulation. Ambiguous genitalia do not develop fully with estrogen
therapy. Ambiguous genitalia can occur in either gender.
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4. An adolescent female is experiencing dysmenorrhea. What should the nurse teach the
patient to help with this disorder?
A) Take acetaminophen (Tylenol).
B) Restrict fluid when having pain.
C) Take over-the-counter ibuprofen.
D) Use ice to help in reducing inflammation and pain.
Ans: C
Feedback:
Dysmenorrhea can usually be controlled by a nonsteroidal anti-inflammatory drug
(NSAID) such as ibuprofen. Tylenol is not identified as a medication to help with the
pain of dysmenorrhea. Fluids do not need to be restricted with dysmenorrhea. Applying
heat to the abdomen with a heating pad, hot shower, or tub bath may relax muscle
tension and relieve pain.
5. A sexually active adolescent female is concerned that she has contracted gonorrhea.
Which finding should the nurse expect to assess if gonorrhea is present in this patient?
A) A low-grade fever for 3 days
B) Painful ulcers on the perineum
C) Slight yellow vaginal discharge
D) A white, frothy vaginal discharge
Ans: C
Feedback:
Although symptoms of gonorrhea in females are not as visible, there may be a slight
yellowish vaginal discharge. The manifestations of a low-grade fever, ulcers on the
perineum, and a frothy white vaginal discharge are not associated with gonorrhea.
6. A sexually active adolescent is scheduled for a pelvic examination. What should the
nurse do to help the patient relax during the examination?
A) Show her a speculum prior to the exam.
B) Assure her that no part of the exam will hurt.
C) Coach her to hold her breath during the exam.
D) Advise her to keep one hand on her abdomen.
Ans: A
Feedback:
Because the first pelvic examination can be stressful, the nurse should spend time with
the girl before the procedure to teach her about what is being assessed. Providing
representative instruments is helpful when describing the examination. There is no
guarantee that no part of the pelvic examination will hurt. The patient should breathe
normally during the examination. Keeping one hand on the abdomen has no significance
during a pelvic examination.
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7. The nurse is instructing a female adolescent about the medication leuprolide acetate
(Lupron Depot-Ped), which has been prescribed to reduce the level of testosterone.
What should the nurse include when teaching the patient about this medication? (Select
all that apply.)
A) Inject in the same region every month.
B) Ensure effective birth control if sexually active.
C) Transfer the medication into another syringe before injecting.
D) Mark on a calendar when the injections are needed every 3 months.
E) Notify the health care provider if nausea and vomiting occurs after taking the
medication.
Ans: B, D
Feedback:
The medication leuprolide acetate (Lupron Depot-Ped) is a pregnancy risk category X
so pregnant should be avoided when taking this medication. Because injections are
given only every 3 months, the patient should prepare a calendar to identify when the
next injection is due. The injections should be varied to decrease local irritation. The
medication should be administered in the syringe supplied. Nausea and vomiting are
possible adverse effects of the medication and do not need to be reported to the health
care provider.
8. What should the nurse instruct an adolescent who asks about the best way to prevent
vulvovaginitis?
A) Wipe from front to back after urinating or defecating.
B) Apply personal hygiene sprays if vaginal odor develops.
C) Soak in a strong bubble bath solution to maintain hygiene.
D) Use nylon rather than cotton underpants to decrease moisture.
Ans: A
Feedback:
To prevent vulvovaginitis, the patient should be instructed to cleanse the perineum from
front to back to prevent spreading rectal contamination forward. Personal hygiene
sprays should be avoided because the ingredients could cause additional irritation.
Bubble baths should be avoided because the ingredients could cause additional
irritation. Cotton underwear should be worn because it allows air to circulate.
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9. A female adolescent is diagnosed with polycystic ovary syndrome. Which information
should the nurse prepare to instruct the patient about the treatment for this disorder?
(Select all that apply.)
A) Importance of exercise
B) Use of antiandrogen medication
C) Eating plan to reach appropriate weight
D) Use of fertility medications to regulate menstrual cycles
E) Use of oral combined estrogen/progesterone contraceptive
Ans: B, C, E
Feedback:
Treatment is aimed at relieving symptoms so teaching should be about symptom
management. Antiandrogen medication may be used to reduce hair growth and acne. An
eating plan may be used to reduce obesity. Oral combined estrogen/progesterone
contraception is used to better regulate menstrual cycles. Exercise is not identified as a
specific treatment. Fertility medication is used if the patient desires to become pregnant
and not to regulate menstrual cycles.
10. An 8-year-old child is diagnosed with balanoposthitis. What will the nurse most likely
assess in this disorder?
A) Reduced production of sperm
B) Pallor of the prepuce of the penis
C) Bloody urethral discharge and pain on urination
D) Denuded, reddened surface of the glans of the penis
Ans: D
Feedback:
Balanoposthitis is inflammation of the glans and prepuce of the penis. The prepuce and
glans appear red and swollen; there may be a purulent discharge. The nurse is unable to
determine sperm production without a sperm count. The child may have difficulty
voiding because of crusting at the meatal opening and because acidic urine touching the
denuded surface of the glans causes pain. A bloody urethral discharge is not associated
with this disorder.
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11. The male partner of a married couple has genital herpes. What should the nurse advise
the couple to prevent the spread of infection to the female partner?
A) Use a condom during intercourse.
B) Avoid intercourse until a Pap test is negative.
C) Delay coitus until 10 days after penicillin is started.
D) Apply acyclovir topically to lesions prior to intercourse.
Ans: A
Feedback:
People with genital herpes should either avoid sexual contact or use a condom to
decrease the danger of spreading the virus. Because of the possible association with
cervical cancer, any female with genital herpes should have yearly Pap tests for the rest
of her life. Penicillin is an antibiotic and is not used to treat genital herpes, which is
caused by a virus. Acyclovir (Zovirax) is an oral medication for genital herpes.
12. An adolescent female is concerned about developing toxic shock syndrome. What
teaching can the nurse provide to allay this patient's fears about the disorder? (Select all
that apply.)
A) Avoid feminine hygiene sprays.
B) Change tampons at least every 4 hours.
C) Take acetaminophen (Tylenol) should a fever occur during menstruation.
D) Use the largest absorbency tampon possible adequate for the menstrual flow.
E) Tampons are to be avoided for 1 month after treatment for toxic shock syndrome.
Ans: A, B
Feedback:
Measures to prevent toxic shock syndrome include avoiding feminine hygiene sprays
because these products can irritate the vaginal lining. Tampons should be changed at
least every 4 hours. If a fever occurs during menstruation, the tampon should be
removed and seek medical attention. A fever is a manifestation of toxic shock
syndrome. The lowest absorbency tampon possible should be used. Anyone who has
had an episode of toxic shock syndrome is advised to avoid all future tampon use.
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13. The nurse instructs an adolescent on preventing the sexually transmitted infection
syphilis. Which statement indicates that teaching about the spread of the infection has
been effective?
A) “In the future, I'll void immediately after sex to prevent this.”
B) “Next time, I'll be smart enough to look at my partner to see if he has any sores.”
C) “I'm lucky I got this early in life. Now, I don't have to worry about getting it
again.”
D) “Can't I be prescribed birth control pills so I'll have some protection from getting
this again?”
Ans: B
Feedback:
Syphilis is a systemic disease transmitted by the spirochete Treponema pallidum. After
an incubation period of 10 to 90 days, a deep ulcer called a chancre, usually painless
despite its size, appears on the genitalia or in the vagina, on the mouth, lips, or rectal
area from oral–genital or genital–anal contact. Voiding after sex will not prevent the
transmission of syphilis. The disease can be transmitted at any time. Immunity does not
develop to syphilis. Birth control pills do not protect from the transmission of syphilis.
14. An 8-year-old female child has been diagnosed with precocious puberty. When teaching
the parents about this diagnosis, what should the nurse include as a priority?
A) “The child will be unable to have children.”
B) “The child will need psychological counseling.”
C) “The child is physically able to become pregnant.”
D) “The child will not need medication to suppress further development.”
Ans: C
Feedback:
Children who develop precociously are fully fertile and are able to conceive.
Psychological counseling is not usually necessary for this disorder. The child will be
able to have children. Medication is used to suppress further development and to ensure
that the long bones do not fuse early.
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15. An adolescent female is diagnosed with fibrocystic breast disease. What advice can the
nurse provide the adolescent about this diagnosis?
A) Caffeine may increase the size of lesions.
B) Fibrocystic lesions are precancerous lesions.
C) Lesions will fade with the full growth of breasts.
D) The lesions make breast self-examination ineffective.
Ans: A
Feedback:
The formation of fibrocystic lesions may be increased in some women with the use of
methylxanthines found in caffeine so avoiding foods such as coffee, cola drinks, tea,
chocolate, some toffee candy, and medications that contain caffeine helps reduce pain.
Fibrocystic lesions are not precancerous. The lesions will not fade with full growth of
the breasts. Breast self-examination is indicated monthly for all women.
16. The nurse is discussing recommended immunizations with the mother of an adolescent
female. Which immunization would be important for the nurse to include during this
discussion?
A) Gardasil
B) Influenza
C) Pneumonia
D) Hepatitis B
Ans: A
Feedback:
The vaccine Gardasil is recommended as part of routine administration to both early
teenage girls and boys to prevent human papillomavirus infections. The nurse should
approach the subject of immunization with parents and teenagers with sensitivity
because some parents and children are not ready to admit they might be or will soon
become sexually active. Influenza vaccination should already be a part of the
adolescent's routine vaccinations. Hepatitis B vaccination should have been completed
at birth and during the first year of life. Pneumonia vaccination is indicated for those in
high-risk groups with respiratory illnesses.
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Chapter 48 Nursing Care of a Family When a Child Has an Endocrine or a
Metabolic Disorder
1. The nurse is caring for a school-age child newly diagnosed with type 1 diabetes
mellitus. Which nursing action supports the 2020 National Health Goals to reduce the
long-term complications from this disease process?
A) Schedule the child and parents to attend diabetes education classes.
B) Explain how the child's physical abilities will be affected during school.
C) Recommend homeschooling so the mother can provide the needed medications.
D) Discuss admission to a rehabilitation facility to learn self-care with this disease
process.
Ans: A
Feedback:
Endocrine disorders tend to be long-term with lifetime consequences. Reducing the
incidence of consequences or improving care has long-term implications. A 2020
National Health Goal related to endocrine disorders includes increasing the proportion
of persons with diabetes who receive formal diabetes education. To support this goal,
the nurse should schedule the child and parents to attend diabetes education classes.
There are no 2020 National Health Goals to address alteration in physical abilities,
homeschooling with type 1 diabetes mellitus, or the need to be admitted to a
rehabilitation facility to learn self-care.
2. The nurse is planning care for a school-age child diagnosed with growth hormone
deficiency. Which diagnosis should the nurse select to help the patient with this health
problem?
A) Risk for situational low self-esteem related to short stature
B) Ineffective tissue perfusion related to infantile blood vessels
C) Impaired skin integrity related to overproduction of melanin
D) Risk for self-directed violence related to oversecretion of epinephrine
Ans: A
Feedback:
Children with short stature tend to report feeling of lower quality of life largely related
to discrimination. The nurse may need to remind parents to assign duties and
responsibilities to children that match their chronologic age, not their physical size, in
order to promote children's feelings of maturity and self-esteem. A child that differs in
any way from peers may be the victim of bullying. The nurse should alert the parent to
this possibility and assess for this at well-child visits to help protect the child's quality of
life. Tissue perfusion is not affected by this disorder. This disorder does not cause
impaired skin integrity. There is no overproduction of epinephrine with this disorder.
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3. The nurse is preparing teaching materials for a family whose child is prescribed
somatropin (Humatrope) for a growth hormone deficiency. What should the nurse
instruct the parents about the administration of this medication?
A) This medication must be given by injection.
B) This medication must be given in the morning before school.
C) Hip or knee pain is an expected adverse effect of this medication.
D) This medication does not interact with any other types of medication.
Ans: A
Feedback:
Somatropin (Humatrope) is administered by injection. It is best given at hour of sleep
because that is when growth hormone is released. Hip or knee pain could indicate a
slipped capital epiphysis and should be reported to the health care provider. The nurse
should urge the parents to inform all health care providers that the child is receiving this
medication to avoid medication interactions.
4. Prior to discharging an infant with congenital hypothyroidism to home with the parents,
what should the nurse emphasize regarding the care that this child will need going
forward?
A) Vitamin K administration until school age
B) Administration of levothyroxine indefinitely
C) An increased intake of calcium beginning immediately
D) Administration of vitamin C until after growth is complete
Ans: B
Feedback:
The treatment for hypothyroidism is oral administration of synthetic thyroid hormone or
sodium levothyroxine. A small dose is given at first, and then the dose is gradually
increased to therapeutic levels. The child needs to continue taking the synthetic thyroid
hormone indefinitely to supplement that which the thyroid does not make. Vitamin K is
not needed. Supplemental vitamin D, and not calcium, may be given to prevent the
development of rickets when rapid bone growth begins. Supplemental vitamin C is not
indicated for this disorder.
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5. A new mother is concerned about the need to provide medication to a newborn every
day for an indefinite period of time. What should the nurse encourage the mother to do
to ensure medication compliance? (Select all that apply.)
A) Check the expiration dates on all medications.
B) Plan times for medications that fit in with the lifestyle.
C) Build medication administration into the general home routine.
D) Make medication administration pleasant such as including it during mealtimes.
E) Schedule prescription refills at least 1 day before the current amount is used up.
Ans: A, B, C
Feedback:
To be successful in giving a medicine over a long time period, the mother should be
urged to build administration into the family's general routine. Expiration dates for the
medication should be checked. Plan the times for medication administration so that it
allows for a normal lifestyle. Having to take medication during mealtimes is not
pleasant and does not support a normal lifestyle. Be certain to anticipate the need to
obtain prescriptions so medicine is always available.
6. A school-age girl is diagnosed as having Cushing syndrome from long-term therapy
with oral prednisone. What assessment finding is consistent with this patient's diagnosis
and treatment?
A) Child appears pale and fatigued.
B) There are purple striae on the abdomen.
C) The child is excessively tall for chronologic age.
D) The child is demonstrating signs of hypoglycemia.
Ans: B
Feedback:
Cushing syndrome is caused by overproduction of the adrenal hormone cortisol. The
overproduction of cortisol results in hyperpigmentation, which occurs from the
melanin-stimulating properties of ACTH. Purple striae resulting from collagen deficit
appear on the child's abdomen. The child will not be pale or fatigued. The child will not
be excessively tall. The child will not be demonstrating signs of hypoglycemia.
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7. The nurse is planning care for a 12-year-old child diagnosed with hyperthyroidism.
Which issue should the nurse anticipate that this child will experience while attending
school?
A) Inability to fit legs under a school desk
B) Noncomprehension of written material
C) Increase in sleepiness by the end of the day
D) Inability to submit neat handwriting assignments
Ans: D
Feedback:
Hyperthyroidism affects coordination, which can be seen in hand tremors. This will
affect the patient's ability to write legibly. Hyperthyroidism does not affect height. This
disease process does not affect cognition so school work will be comprehensible.
Hyperthyroidism does not cause sleepiness.
8. A newborn female is discovered to have congenital adrenogenital hyperplasia. What
will the nurse most likely observe when assessing this patient?
A) Enlarged clitoris
B) Divergent vision
C) Small for gestational age
D) Abnormal facial features
Ans: A
Feedback:
Congenital adrenal hyperplasia is a syndrome that is inherited as an autosomal recessive
trait, which causes the adrenal glands to not be able to synthesize cortisol. Because the
adrenal gland is unable to produce cortisol, the level of ACTH secreted by the pituitary
in an attempt to stimulate the gland to increase function is increased. Although the
adrenals enlarge under the effect of ACTH, they still cannot produce cortisol but rather
overproduce androgen. Excessive androgen production during intrauterine life
masculinizes the genital organs in a female fetus so that the clitoris is so enlarged it
appears to be a penis. This disorder does not cause divergent vision. The child will not
be born small for gestational age. This disorder does not cause abnormal facial features.
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9. A mother, distressed to learn that her school-age child is diagnosed with type 2 diabetes
mellitus, asks the nurse how this could happen because no one in the family has
diabetes. What should the nurse explain to the mother?
A) “This is caused by the pancreas not making enough insulin.”
B) “This disorder usually occurs when inadequate calories are ingested on a regular
basis.”
C) “Because this disorder is genetic, someone in the family will eventually develop
the illness.”
D) “This disorder is associated with overweight and eating a diet high in fats and
carbohydrates.”
Ans: D
Feedback:
Type 2 diabetes is now seen in overweight adolescents and those who eat a diet high in
fats and carbohydrates and do not exercise regularly. Type 2 diabetes is not caused by
the pancreas not making enough insulin. This disorder is not linked to an inadequate
ingestion of daily calories. This disorder may have a genetic link, but environmental
factors such as obesity, diet, and exercise can influence its development.
10. A newborn is diagnosed with the salt-losing form of congenital adrenogenital
hyperplasia. On what should the nurse focus when assessing this patient?
A) Dehydration
B) Hypoglycemia
C) Bleeding tendency
D) Excessive cortisone secretion
Ans: A
Feedback:
If there is a complete blockage of cortisol formation, aldosterone production will also be
deficient. Without adequate aldosterone, salt is not retained by the body, so fluid is not
retained. Almost immediately after birth, affected infants begin to have vomiting,
diarrhea, anorexia, loss of weight, and extreme dehydration. If these symptoms remain
untreated, the extreme loss of salt and fluid can lead to collapse and death as early as 48
to 72 hours after birth. The salt-losing form must be detected before an infant reaches an
irreversible point of salt depletion. This disorder does not cause hypoglycemia,
excessive bleeding, or excessive cortisone secretion.
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11. Shortly after delivery, a newborn is diagnosed with hypocalcemia. What manifestation
will the nurse assess in this patient?
A) Jitteriness
B) Constipation
C) Excessive sleepiness
D) A distended abdomen
Ans: A
Feedback:
The chief sign of hypocalcemia is neuromuscular irritability, referred to as latent tetany.
This occurs if the blood calcium level falls below 7.5 mg/dl. The newborn will
demonstrate jitteriness when handled or has been crying for an extended period.
Constipation, excessive sleepiness, and a distended abdomen are not manifestations of
hypocalcemia.
12. The nurse is caring for a 3-year-old child diagnosed with phenylketonuria. Which food
should the nurse remove before providing the child with a lunch tray?
A) Orange juice
B) Lettuce leaves
C) A sliced banana
D) Chocolate pudding
Ans: D
Feedback:
Phenylketonuria (PKU) is a disease of metabolism, which is inherited as an autosomal
recessive trait. The infant lacks the liver enzyme phenylalanine hydroxylase, which is
necessary to convert phenylalanine, an essential amino acid, into tyrosine. Excessive
phenylalanine levels build up in the bloodstream and tissues, causing permanent damage
to brain tissue and leaving children severely cognitively challenged. Dietary restriction
is the main treatment of PKU. Foods highest in phenylalanine are those that are rich in
protein, such as meats, eggs, and milk. Foods low in phenylalanine include fruit juices,
bananas, and lettuce. Pudding is forbidden because it is made with milk.
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13. The nurse is explaining to the parents of a school-age child with type 1 diabetes mellitus
how the health care provider determines the daily insulin dose. The child is prescribed
to receive 0.5 units/kg of body weight of intermediate-acting and short-acting insulin at
the ratio of 2:1. Because the child weighs 66 lb, how many units of the short-acting
insulin will the health care provider prescribe? (Enter numeric value only.)
Ans: 5 units
Feedback:
The nurse should first determine the patient's weight in kilograms by dividing 66 lb by
2.2 or 66 / 2.2 = 30 kg. Then the nurse should multiple the prescribed dose of insulin by
the body weight or 0.5 × 30 = 15. Then the nurse will need to determine the amount of
intermediate-acting and short-acting insulin according to the ratio of 2:1. If the patient is
to receive two parts of intermediate-acting insulin to one part of short-acting insulin, the
total volume of 15 units can be divided by 3. The patient should be prescribed to receive
10 units of intermediate-acting insulin and 5 units of short-acting insulin.
14. A mother caring for a school-age child with type 1 diabetes mellitus is frantic because
the child self-administered 15 units of regular insulin instead of the prescribed 5 units
before breakfast this morning. What should the nurse instruct the mother to do at this
time? (Select all that apply.)
A) Observe for nervousness, weakness, dizziness, or sweating.
B) Determine if the child is experiencing extreme hunger and thirst.
C) Determine if the child is irritable or demonstrating stubbornness.
D) Provide the child with a half-glass of orange juice or regular soda.
E) Rub a small amount of honey on the child's gums and inside of the cheek.
Ans: A, C, D, E
Feedback:
Symptoms of hypoglycemia occur when the blood glucose level falls to about 60 mg/dl
and results from the administration of too much insulin. Beginning symptoms include
nervousness, weakness, dizziness, or sweating. In many children, the first signs of
hypoglycemia are behavior problems such as stubbornness and irritability. When the
signs of hypoglycemia are recognized, a child needs an immediate source of
carbohydrate such as a half glass of orange juice or regular soda. If the child is comatose
when first discovered or is too upset or uncooperative to take oral sugar, parents can rub
glucose onto the gums or inside the cheek by using honey or other sweet substance.
Extreme hunger and thirst are manifestations of hyperglycemia or an inadequate amount
of insulin.
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15. The nurse instructs a preadolescent child with type 1 diabetes mellitus how to
self-administer an injection of short-acting and long-acting insulin. Which observation
indicates to the nurse that teaching has been successful?
A) Administers the insulin intramuscularly
B) Wipes off the needle with an alcohol swab
C) Administers the insulin at a 30-degree angle
D) Draws up the short-acting insulin into the syringe first
Ans: D
Feedback:
Patients should be taught that when insulin is being mixed in one syringe, the regular or
short-acting insulin should be drawn into the syringe first. Insulin is injected into
subcutaneous tissue. The needle should not be wiped off with alcohol before injecting.
Insulin should be administered at a 90-degree angle to the skin surface.
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Chapter 49 Nursing Care of a Family When a Child Has a Neurologic Disorder
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.
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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.
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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.
6. The nurse is caring for a preschool-age child recovering from a lumbar puncture. What
should the nurse do to ensure the patient does not develop a spinal headache?
A) Measure temperature every hour.
B) Restrict fluids for 2 hours after the procedure.
C) Elevate the head of the bed to a 30-degree angle.
D) Take the pillow away and have the patient lie flat in bed.
Ans: D
Feedback:
A child may develop a headache after a lumbar puncture as a result of the reduction in
CSF volume or invasion of a small air pocket during the puncture. The nurse should
encourage the child to lie flat for at least 30 minutes. The child's blood pressure, pulse,
and respirations should be assessed for changes that indicate an increase in intracranial
pressure. The child should drink a glass of fluid after the procedure to help prevent
cerebral irritation caused by air rising in the subarachnoid space and to help increase the
amount of CSF. The head of the bed should be flat and not elevated to a 30-degree
angle.
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7. The nurse instructs the parents of a child with Guillain-Barré syndrome on care that will
be needed once the child is discharged home. Which statement made by the parents
indicates that teaching has been effective?
A) “We need to be sure to change our child's body position at least twice a day.”
B) “Our child might experience weakness even after recovering from the illness.”
C) “It will take about 10 days for our child to be back normal and return to school.”
D) “This disease affects the heart and lungs, so our child will have limited ability
going forward.”
Ans: B
Feedback:
Most children recover completely, without any residual effects of the syndrome;
although, some may continue to have minor problems such as residual weakness. To
prevent muscle contractures and effects of immobility, turning and repositioning every 2
hours is important in addition to passive range-of-motion exercises about every 4 hours.
It will take longer than 10 days for the child to recover and return to school. This disease
does not directly affect the heart and lungs. There should be minimal residual disability
going forward.
8. An adolescent recovering from a spinal cord injury calls out for help. The patient's face
is bright red, and the patient is experiencing a severe headache. What is the first thing
that the nurse should do for this patient?
A) Administer mouth-to-mouth resuscitation.
B) Assess if the urinary retention catheter is blocked.
C) Massage the lower extremities to cause vasodilation.
D) Lower the head of the bed to increase cerebral circulation.
Ans: B
Feedback:
The patient is demonstrating signs of autonomic dysreflexia, which include extreme
hypertension, tachycardia, flushed face, and severe occipital headache. This can occur if
the patient's bladder is allowed to fill. The resultant sensory stimulation relayed to the
damaged cord can initiate a powerful sympathetic reflex reaction. The nurse should
assess that the patient's urinary catheter is not obstructed, so urine can flow freely and
reduce the sensory stimulation. The patient is talking, so mouth-to-mouth resuscitation
is not necessary. Massaging the lower extremities and lowering the head of the bed will
not relieve the sensory stimulation caused by the blocked urinary catheter.
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9. The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy.
Which assessment finding supports this medical diagnosis?
A) The child has a strong Moro reflex when startled.
B) The child bears weight on both feet when held upright.
C) The child cries when held in a ventral suspension position.
D) The child holds the back very straight when in a sitting position.
Ans: A
Feedback:
Spasticity is excessive tone in the voluntary muscles that results in loss of upper motor
neurons. A child with spastic cerebral palsy has hypertonic muscles, abnormal clonus,
exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski
reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the
age at which these usually disappear. If infants with this disorder are held in a ventral
suspension position, they arch their backs and extend their arms and legs abnormally.
They tend to assume a “scissors gait” because tight adductor thigh muscles cause their
legs to cross when held upright. This involvement may be so severe it leads to a
subluxated hip. Posture when in a sitting position is not remarkable for this health
problem.
10. A preadolescent child with ataxia-telangiectasia is demonstrating an exacerbation of
choreoathetosis. What should the nurse do to help this patient?
A) Provide comfort measures.
B) Assist the patient to walk several times a day.
C) Encourage the patient to increase independence.
D) Recommend transferring the patient to a rehabilitation facility.
Ans: A
Feedback:
Ataxia-telangiectasia is a primary immunodeficiency disorder that results in progressive
cerebellar degeneration. Telangiectasia or red vascular markings appear on the
conjunctiva and skin at the flexor creases. Neurologic symptoms caused by the
degeneration process can usually be detected in early infancy when developmental
milestones are not met. Children develop an awkward gait when they begin to walk.
Choreoathetosis or rapid, purposeless movements may develop. Unfortunately, there is
no effective treatment, and children with this disorder often die in late adolescence of
infection, respiratory failure, or a malignant brain tumor. The nurse should provide
comfort measures when caring for this child. The patient may not be able to walk. It is
an unrealistic expectation for this child to increase independence. A rehabilitation
facility is not going to help with the long-term prognosis of this disorder.
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11. An 8-year-old child is being treated for tonic–clonic seizures. What should the nurse
emphasize when teaching the parents about this disorder?
A) The child should maintain an active lifestyle.
B) Immediately provide medication if a seizure begins.
C) Have the child carry a padded tongue blade with her at all times.
D) Ensure quiet time late in the day, when seizure activity is most likely to occur.
Ans: A
Feedback:
As a rule, children with seizures should attend regular school and participate in physical
education classes and active sports. Antiseizure medication is ineffective during a
seizure because most medication needs to achieve a therapeutic level to be effective.
Padded tongue blades are not used in people with a seizure disorder. There is no specific
time of day when a seizure can occur.
12. A preadolescent weighing 99 lb is prescribed carbamazepine (Tegretol) 10 mg/kg per 24
hours in two divided doses. How much medication will the nurse provide the patient for
one dose? (Enter numeric response only.)
Ans: 225 mg
Feedback:
The nurse needs to first determine the patient's weight in kilograms by dividing 99 lb by
2.2 or 99 / 2.2 = 45 kg. Next, the nurse is to multiply the prescribed dose of 10 mg by
the body weight in kilograms or 10 × 45 = 450. If the child is to receive 450 mg of the
medication in 24 hours, divide this total by 2 to determine that the child is to receive 225
mg for each dose.
13. The nurse is caring for a child with a closed head injury. The child's blood pressure is
120/58 mmHg, and intracranial pressure is 16 mmHg. What is this child's cerebral
perfusion pressure? (Enter numeric value only. Calculate to the nearing hundredth
decimal point.)
Ans: 84.67
Feedback:
Cerebral perfusion pressure is calculated by subtracting the mean intracranial pressure
from the mean arterial pressure or MAP – ICP = CPP. To calculate mean arterial
pressure, the nurse should subtract the diastolic blood pressure from the systolic blood
pressure and divide the result by 3 and then add that sum to 80. For this patient, the
MAP would be calculated as being (120 – 58) / 3 + 80 = 100.67. To calculate the
cerebral perfusion pressure, take the value of the mean arterial pressure and subtract the
child's intracranial pressure or 100.67 – 16 = 84.67. The child's cerebral perfusion
pressure is 84.67.
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14. The nurse is assessing pupil size and reaction to light in a child with a cervical neck
injury. Which cranial nerve is the nurse assessing in this patient?
A) II (optic)
B) III (oculomotor)
C) IV (trochlear)
D) VI (abducens)
Ans: B
Feedback:
Cranial nerve III (oculomotor) provides motor control and sensation for eye muscles and
the upper eyelid. To determine the functioning of this nerve, the nurse would assess
pupillary size and reaction to light. Cranial nerve II controls vision. Cranial nerve IV
controls the movement of major eye muscles. Cranial nerve VI controls the movement
and muscle sense of the eye.
15. The nurse is planning care for a preschool-age child diagnosed with meningitis. What
should the nurse identify as a priority goal for this patient's care?
A) Inspect the teeth for obvious caries.
B) Reduce the pain related to nuchal rigidity.
C) Provide an opportunity for therapeutic play.
D) Increase stimulation opportunities to prevent coma.
Ans: B
Feedback:
Meningitis is an infection of the cerebral meninges. Pathologic organisms spread to the
meninges. Once organisms enter the meningeal space, they multiply rapidly and then
spread throughout the CSF to invade brain tissue through the meningeal folds, which
extend down into the brain itself. A child with meningitis usually has an upper
respiratory tract infection prior to the development of meningitis. Then the child will
become increasingly irritable because of an intense headache with sharp pain when
bending the head forward. Reducing the pain caused by neck pain would be the priority
goal for this patient's care. Inspecting the teeth, providing opportunities for play, and
increasing stimulation would not be priority goals for this patient.
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Chapter 50 Nursing Care of a Family When a Child Has a Vision or Hearing Disorder
1. The nurse is caring for a 10-year-old child with bacterial conjunctivitis of the right eye.
The eye is inflamed and drains a thick, yellow discharge. What should the nurse teach
the patient about the care of the eye?
A) Do not attend school for 2 weeks.
B) Use ophthalmic drops for 3 days.
C) Keep the eye covered at all times.
D) Clean the discharge away from the inner to outer canthus.
Ans: D
Feedback:
Conjunctivitis is inflammation of the conjunctiva that causes pustular drainage. The eye
should be cleansed from the inner to the outer canthus to prevent the spread of infection
to the other eye. School does not need to be missed for 2 weeks with this eye infection.
Ophthalmic medication should be used as prescribed, which might be longer than 3
days. The eye does not need to be covered.
2. A mother is concerned that her toddler is diagnosed with amblyopia. What should the
nurse explain as possible treatments for this eye condition? (Select all that apply.)
A) Wearing corrective eye glasses
B) Covering the good eye with a patch
C) Using a patch and corrective eye glasses
D) Applying eye drops prior to applying an eye patch
E) Scheduling for immediate surgery to cut the eye muscle
Ans: A, B, C, D
Feedback:
Treatment for amblyopia can consist of wearing correcting glasses, covering the good
eye with a patch, or a combination of the two. An additional option is using the
medication levodopa and an eye patch. LASIK surgery might be considered, which
corrects the refractive error but does not cut the eye muscle.
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3. The outpatient care clinic receives the 2020 National Health Goals that focus on
prevention, early detection, treatment, and rehabilitation of vision problems. What
should the nurse remind each patient to do to ensure eye health?
A) Flush the eyes every day with cool water.
B) Instill artificial tears in the eyes at least twice a day.
C) Cleanse the eyes with soap and warm water while taking a shower.
D) Use personal protective eyewear during recreation and hazardous situations.
Ans: D
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals that focus on
prevention, early detection, treatment, and rehabilitation of vision problems by
reminding all patients to use personal protective eyewear in recreational activities and
hazardous situations around the home. This goal will not be met by instructing patients
to flush the eyes with water, use artificial tears, or cleanse the eyes with soap and warm
water.
4. A school-age child comes into the emergency department with tearing and pain in the
right eye. Which method will the nurse use to assess for foreign body under the upper
eye lid?
A) Evert the upper lid.
B) Apply topical anesthesia to the upper lid.
C) Apply cool water to the lid to cause it to retract.
D) Catch the child's attention with a toy so that he looks down.
Ans: A
Feedback:
Foreign bodies such as sand or dirt that are loose on the conjunctiva can be removed by
gentle wiping with a well-moistened, sterile, cotton-tipped applicator after the eyelid is
everted. Topical anesthetic, cool water, and diversion are not appropriate methods to
assess for a foreign body under the upper eye lid.
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5. When assessing school-age children for vision problems, which child would be most
important for the nurse to assess for a deficiency in color perception?
A) A girl who was born prematurely
B) A boy who does not participate well in art class
C) A boy who has had frequent middle ear infections
D) A girl whose teacher reports that she rubs her eyes
Ans: B
Feedback:
Color deficit is the inability to perceive color correctly. It occurs in 4% to 8% of boys
because one of the sets of cones of the retina that perceive red, green, or blue is absent.
It is important for the loss of color perception to be detected early so the child can learn
changes in traffic signals or other color-dependent signs necessary for safety. The child
who does not participate well in art class could be color blind. Since this is a condition
that occurs in boys, the girls do not need to be assessed for color deficit. Color deficit is
not associated with ear infections.
6. During a routine hearing test, a school-age boy is discovered as having a hearing level
of 60 dB. What does this finding indicate to the nurse about the child's ability to hear?
A) Whispering only
B) Very loud noises only
C) Able to hear all noises and sounds
D) Difficulty with normal conversation
Ans: D
Feedback:
At the hearing level of 60 dB, the person will have difficulty with normal conversation.
A person who can hear whispered words is not experiencing a hearing loss. The person
who can only hear loud noises would have a severe hearing loss at the decibel level
between 70 and 90. The person who is able to hear all noises and sounds is not
experiencing a hearing loss.
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7. The nurse is planning care for a toddler who is diagnosed with a profound hearing loss.
Which nursing diagnosis should the nurse identify as the priority once the child is
discharged?
A) Risk for injury related to hearing loss
B) Social isolation related to effects of hearing loss
C) Impaired verbal communication related to congenital hearing deficit
D) Risk for parental role strain related to responsibilities of caring for sensory
impaired child
Ans: A
Feedback:
The child is a toddler and will be exploring areas throughout and outside of the home.
With a hearing deficit, the child will not be able to hear any warnings from the parents.
This increases the child's risk of injury related to the hearing loss. The child may or may
not experience social isolation from the hearing loss. It is too soon to determine if the
child will have impaired verbal communication, and it is unknown if the hearing deficit
is congenital. The parents will be challenged to care for a sensory impaired child;
however, the child's risk for injury would be the priority.
8. The nurse is caring for a preschool-age child diagnosed with acute otitis media. Which
intervention should be a priority for the nurse?
A) Relieving pain
B) Administering a mydriatic
C) Cautioning the child not to blow the nose
D) Cautioning the child not to pull on the ear
Ans: A
Feedback:
Acute otitis media causes sharp, constant pain in one or both ears. Older children can
verbalize they have pain and point to where it is at. Relief of pain should be the nurse's
priority when caring for this patient. A mydriatic is a medication for an eye disorder.
There is no reason why the child cannot blow the nose. Pulling on the ear is an attempt
to reduce the pain.
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9. The nurse is preparing a program for the parents of school-age children on ways to
prevent hearing loss. What information should the nurse include in this program?
(Select all that apply.)
A) Avoid placing any objects into the ears.
B) Ensure that all immunizations are current.
C) Use over-the-counter remedies to treat sore throats.
D) The impact of chronic exposure to loud music when using earphones.
E) Protect the ears with earplugs or earmuffs when in loud environments.
Ans: A, B, D, E
Feedback:
Strategies to protect hearing include not placing any objects into the ears, ensuring that
all immunizations are current, understanding the impact of chronic exposure to loud
music when using earphones, and protecting the ears when in loud environments. The
nurse should teach that prompt treatment should be obtained for sore throats because
these can lead to middle ear infections.
10. The nurse instructs a hearing-impaired school-age child on to how self-inject a
prescribed medication. Which observation indicates to the nurse that additional teaching
is required?
A) The child pinches the skin together before inserting the needle.
B) The child injects the appropriate amount of air into the vial before withdrawing
medication.
C) The child places the filled syringe and uncapped needle on the bed to open the
alcohol wipe.
D) The child slowly pushes on the plunger to inject the medication before
withdrawing the needle.
Ans: C
Feedback:
Children who are unable to hear may need additional time for explanations and support.
By placing the syringe and uncapped needle on the bed, the child is contaminating the
needle. This would indicate that additional teaching is necessary. Pinching the skin,
injecting air, and slowly pushing on the plunger all indicate that teaching has been
effective.
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11. A child having myringotomy tubes placed asks, “How and when will the tubes be
removed?” What should the nurse respond to this patient?
A) “The tubes are not removed; they grow permanently into place.”
B) “You will have them replaced every 2 months until you reach age 18 years.”
C) “The tubes remain in place for 6 months and then are dissolved by vinegar.”
D) “The tubes remain in place for 6 to 12 months until they come out by themselves.”
Ans: D
Feedback:
Tubes tend to be extruded or come out by themselves after 6 to 12 months. The tubes do
not grow permanently into place. They will not need to be replaced every 2 months, and
they are not dissolved by vinegar.
12. The nurse is planning care for a school-age child with a black eye. Which outcome
would be the most appropriate for this patient?
A) The swelling will be reduced in a month.
B) Evidence of bleeding will be reabsorbed within 1 to 3 weeks.
C) The child will have double vision upon waking in the morning.
D) The child will begin wearing corrective lenses after the swelling subsides.
Ans: B
Feedback:
For an eye contusion or a black eye, an appropriate outcome would be for evidence of
the bleeding to be reabsorbed within 1 to 3 weeks. The swelling should be reduced
much sooner than a month. The child should not experience any double vision with a
black eye. The child will not need to be prescribed corrective lenses because of a black
eye.
13. The nurse is caring for a child recovering from surgery to correct strabismus. Which
interventions should the nurse include when planning this child's care? (Select all that
apply.)
A) Apply an eye patch.
B) Maintain on bed rest for 3 days.
C) Support for nausea and vomiting.
D) Provide pain medication as prescribed.
E) Apply antibiotic ointment as prescribed.
Ans: C, D, E
Feedback:
After eye surgery for strabismus, the patient may experience nausea and vomiting and
pain on eye movement. The patient will also be prescribed antibiotic ointment. An eye
patch is not usually required. The child will not need to be on bed rest for 3 days.
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14. A school-age child who is blind is hospitalized for another health problem. What should
the nurse say when providing the child with a meal tray?
A) “Here is your tray; if you need help, just call me.”
B) “I'll have to feed you lunch; spaghetti is very messy.”
C) “I have cut your meat for you. Do you need any other help?”
D) “You have a sandwich on your plate, a glass of milk to your right, and an apple to
your left.”
Ans: D
Feedback:
Children who are blind often want to be told what is on their food tray when it is first
presented to them. Name the foods so they can identify tastes with names as well as
location of foods on the plate. The child needs to know what is on the meal try and
should not be expected to call for help. Children with vision disorders have difficulty
getting food from spoons or forks to their mouths neatly. However, they should not be
spoon-fed just because it is neater and faster; eating is an important self-care skill a
blind child must learn in order to be independent as an adult. The nurse needs to do
more than cut the child's meat. The child has no way of knowing where any of the food
is located on the tray.
15. An infant born with congenital glaucoma is scheduled for surgery. Which preoperative
order should the nurse question for this patient?
A) A preoperative antibiotic
B) Nothing by mouth prior to surgery
C) A preoperative injection of atropine
D) Arm restraints to be applied after surgery
Ans: C
Feedback:
Before surgery, the infant should not receive any drug, such as atropine sulfate, that
dilates the pupil because this will further occlude the canal of Schlemm. Preoperative
antibiotics, nothing by mouth before surgery, and the use of arm restrains after surgery
are all orders that would be appropriate for the care of this child.
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Chapter 51 Nursing Care of a Family When a Child Has a Musculoskeletal Disorder
1. A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority
intervention when planning this child's care?
A) Assisting the child with crutch walking
B) Maintaining intravenous antibiotic therapy
C) Keeping the child quiet while in skeletal traction
D) Restricting fluid to encourage red cell production
Ans: B
Feedback:
For osteomyelitis, medical therapy includes administration of intravenous antibiotics,
which is usually initiated in the hospital and then continued at home for as long as 2
weeks; an intermittent infusion device or peripherally inserted central catheter may be
used. After this, the child will be prescribed an oral antibiotic for 3 to 4 more weeks.
There is no enough information to determine the location of the infection so crutch
walking may not be applicable. Skeletal traction is not needed to treat osteomyelitis.
Fluid restriction does not encourage red blood cell production and may be harmful to the
care of this child.
2. A school-age child with pauciarticular juvenile arthritis has extreme pain upon waking
in the morning. Which intervention should the nurse suggest the parents try to help the
child with the pain?
A) Encourage bed rest until the pain is gone.
B) Perform isotonic exercises until the pain is gone.
C) Provide 325 mg of aspirin immediately on arising.
D) Encourage a warm bath each morning before school.
Ans: D
Feedback:
Heat reduces pain and inflammation in joints and increases comfort and motion. Heat
can be applied by the use of a heating pad or warm water soaks for 20 to 30 minutes.
Bed rest will not help reduce the pain. Isotonic exercises will not reduce the pain and
could make the pain worse. Aspirin taken on an empty stomach could lead to gastric
irritation. The dose of 325 mg may also be too high for the child.
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3. The nurse is preparing an educational session for community members that focuses on
the 2020 National Health Goals. Which information should the nurse include to ensure a
healthy musculoskeletal system?
A) Importance of daily exercise
B) Early diagnosis of painful joints
C) Need for at least 8 hours of sleep
D) Ensure an adequate intake of calcium
Ans: A
Feedback:
The 2020 National Health Goals focus on proper exercise to maintain a healthy
musculoskeletal system. The nurse can help the nation achieve these goals by educating
community members on the importance of physical activity. Diagnosis of painful joints,
hours of sleep, and dietary intake are not identified as actions to ensure a healthy
musculoskeletal system.
4. The nurse is evaluating a school-age child's ability to crutch walk so that no weight is
placed on an injured leg. Which walking technique indicates that teaching has been
effective?
A) Walking gait
B) Two-point gait
C) Single-crutch support gait
D) Three-point swing-through gait
Ans: D
Feedback:
A three-point swing-through gait is used when no weight bearing is allowed on one foot.
A two-point gait is used when a child needs support for weakened muscles or balance
but may bear weight on both lower extremities. Walking gait and single-crutch support
gait are not identified crutch walking approaches.
5. The nurse is caring for a child who has just received a cast for a broken wrist. Why
should the nurse elevate the limb onto a pillow?
A) To prevent edema
B) To promote healing
C) To discourage infection
D) To ensure proper bone alignment
Ans: A
Feedback:
If an extremity has been casted, keep it elevated with a pillow to prevent edema in the
fractured area. Elevating a casted extremity does not promote healing or discourage
infection. The cast will ensure proper bone alignment.
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6. The nurse is concerned that a preschool-age child is demonstrating signs of Duchenne
muscular dystrophy. What did the nurse assess in this child?
A) Gower sign
B) Facial weakness
C) Inability to whistle
D) Inadequate use of respiratory muscles
Ans: A
Feedback:
Children with Duchenne muscular dystrophy usually have a history of meeting motor
milestones, but by about 3 years of age, symptoms are more acute and obvious. Rising
from the floor is done by rolling onto the stomach and then pushing up to the knees. To
stand, the hands are pressed against the ankles, knees, and thighs. This is Gower sign.
Facial weakness and inability to whistle are manifestations of facioscapulohumeral
muscular dystrophy. Inadequate use of respiratory muscles is a manifestation of
congenital myotonic dystrophy.
7. The nurse is instructing the mother of a school-age child with a leg cast about cast care
at home. What should the nurse include in this teaching? (Select all that apply.)
A) Cover the cast with a plastic bag to bathe.
B) Remind that nothing is to be put down the cast.
C) Recommend using magic markers for autographs.
D) Use the cool setting on a hair dryer to ease itchy skin.
E) Encourage usual activities but restrict strenuous actions.
Ans: A, B, D, E
Feedback:
When teaching the mother about cast care at home, the nurse should include covering
the cast with a plastic bag while bathing so the cast does not get wet, not placing
anything down the cast, using the cool setting on a hair dryer to ease itching, and
encourage usual activities but reducing strenuous activities while the cast is in place.
Magic markers should not be used for autographs because the ink can seep into the cast
material.
8. A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse
teach the child about the purpose of the brace?
A) Prevents torticollis
B) Improves spinal stability
C) Corrects spinal curvature
D) Prevents herniation of a spinal disk
Ans: B
Feedback:
The goal of mechanical bracing is to maintain spinal stability and prevent further
progression of the deformity until bone growth is complete. Bracing will not prevent
torticollis, correct the curvature, or prevent herniation of a spinal disk.
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9. The nurse is caring for a school-age child newly diagnosed with juvenile arthritis.
Which diagnosis would be a priority for this patient?
A) Knowledge deficit related to care needs
B) Risk for inefficient peripheral tissue perfusion
C) Ineffective coping related to physical limitations
D) Imbalanced nutrition: less than body requirements
Ans: A
Feedback:
With newly diagnosed juvenile arthritis, the child and family will need to learn how to
manage the symptoms by planning exercise and medication programs around school or
other activities. Juvenile arthritis does not affect peripheral tissue perfusion. Because the
child is newly diagnosed, it is premature to use the diagnosis of ineffective coping.
There is no evidence that the child has imbalanced nutrition.
10. A school-age child is scheduled for a muscle biopsy. What should the nurse teach the
patient about the procedure?
A) Medication will be given so pain is minimized.
B) The amount of muscle tissue taken is about 2 in.
C) Bed rest for several days will need to be done afterward.
D) Long-term pain medication will be needed after the procedure.
Ans: A
Feedback:
Muscle biopsies are usually done using conscious sedation and a local anesthetic. The
amount of tissue taken is about the size of the lead in a pencil. There is no need for bed
rest for several days after the procedure. This procedure does not cause long-term pain.
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11. A school-age child with a supracondylar fracture of the humerus has been placed in a
partial cast with the elbow region wrapped with an elastic bandage. What should the
nurse explain to the parents and child regarding the reason for this type of casting
approach?
A) Encourages healing
B) Ensures edema does not press on the nerves
C) Keeps the bones of the forearm in alignment
D) Provides additional stability until the bone heals
Ans: B
Feedback:
With an elbow fracture, the arm will be flexed and put into a cast. In this position, the
radial artery and nerve can be compressed at the elbow, causing nerve injury or severe
impairment of circulation. In some situations, a cast is applied incompletely for 24
hours, the elbow portion being splinted and wrapped with elastic bandages. After 24
hours, when edema has subsided and the chance of compression is less, the rest of the
arm is then casted. The use of an elastic wrap at the elbow is not used to encourage
healing, keep the bones in alignment, or provide additional stability.
12. The nurse receives report from the admission department that a child with a slipped
femoral epiphysis is en route to the care area. For which type of child should the nurse
begin to plan care?
A) Tall, thin female
B) Preadolescent female
C) Active school-age male
D) Obese preadolescent male
Ans: D
Feedback:
A slipped femoral epiphysis is a slipping of the femur head in relation to the neck of the
femur at the epiphyseal line. This disorder occurs most frequently in preadolescence and
its highest incidence is in obese children. It is twice as frequent in boys as girls.
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13. The nurse is planning teaching for the parents of a child with Legg-Calvé-Perthes
disease. On what should the nurse emphasize when conducting this teaching?
A) Surgery is needed with supporting rods.
B) The child will have a non–weight-bearing period.
C) The child will need passive range-of-motion exercises three times a day.
D) The child will need to exercise to increase muscle strength of the knee joint.
Ans: B
Feedback:
For Legg-Calvé-Perthes disease, both parents and the child need thorough education
about treatment and care because it can be difficult for young children to accept the
extended treatment period involved with this disorder. There are long-term
consequences if rest is not followed conscientiously. Parents may need assistance with
devising appropriate activities for the child during the time that activity is limited and
weight bearing is not allowed. Surgery with supporting rods is used to treat scoliosis.
The child will not have passive range-of-motion exercises nor knee joint exercises in the
treatment of this disease.
14. The nurse is caring for a school-age child recovering from an open reduction for a
fractured femur. Which assessment findings indicate that the child is developing an
infection? (Select all that apply.)
A) Lethargy
B) Increased pulse rate
C) Reduced pulse in the ankle
D) Cyanosis of the casted foot
E) Increased body temperature
Ans: A, B, E
Feedback:
Children with an open reduction are prone to infection. The nurse should suspect an
infection if the systemic symptoms of increased pulse, increased temperature, and
lethargy are present. Reduced pulse in the ankle and cyanosis of the casted foot are
manifestations of compartment syndrome.
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Chapter 52 Nursing Care of a Family When a Child Has an Unintentional Injury
1. A 2-year-old child is diagnosed with lead poisoning caused by eating paint chips from a
windowsill. What measure should the nurse instruct the parents to prevent this from
occurring in the future?
A) Teaching their daughter that paint is not an edible substance
B) Not allowing their daughter any milk products during daylight hours
C) Covering the windowsills with paneling to prevent her from reaching them
D) Administering ipecac syrup the next time they see her eat a paint chip
Ans: C
Feedback:
Active interventions need to begin to prevent further lead exposure such as removal of
the child from the environment containing the lead source or removal of the source of
lead from the child's environment. Removal of the lead source is not an easy task in
homes because simple repainting or wallpapering does not necessarily remove the
source of peeling paint adequately. After some months, the new paint will begin to peel
because of the defective paint underneath. The walls must therefore be covered by
paneling or dry wall or other solid protective material. The child is 2 years old and will
not understand that paint is not edible. Milk products will not prevent future episodes of
lead poisoning. Syrup of ipecac will not help with the metabolism of lead from paint
chips.
2. A child with a head injury is demonstrating signs of cognitive deficits. The parents are
concerned about how well the child will recover. Which nursing diagnosis should the
nurse identify as the most appropriate for the family at this time?
A) Anxiety related to extent of required hospitalization
B) Risk for long-term learning deficits related to head injury
C) Parental fear related to outcome after head injury in child
D) Ineffective coping related to care of a child with a head injury
Ans: C
Feedback:
The parents are concerned if the child will recover. The most appropriate nursing
diagnosis would be parental fear related to outcome after head injury. The parents are
not demonstrating anxiety related to the hospitalization. Even though the child is
demonstrating cognitive deficits at this time, this can change. The recovery from a head
injury is unpredictable so deficits can resolve. The parents are not providing care to the
child at this time, so there is no evidence of ineffective coping related to the care of a
child with a head injury.
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3. An infant is brought to the emergency department with acetaminophen poisoning.
Which medication should the nurse expect to administer to this child?
A) Iron
B) Deferoxamine
C) Acetylcysteine
D) Dexamethasone
Ans: C
Feedback:
In the emergency department, acetylcysteine, a mucolytic agent and also the specific
antidote for acetaminophen poisoning, will be administered. Acetylcysteine prevents
hepatotoxicity by binding with the breakdown product of acetaminophen so that it will
not bind to liver cells. Iron, deferoxamine, and dexamethasone are not used as antidote
for acetaminophen poisoning.
4. The nurse is completing the health history for the parents of school-age child admitted
with a ruptured spleen. For which activity should the nurse assess as the possible cause
for this child's injury?
A) Shooting pool
B) Skateboarding
C) Playing baseball
D) Playing basketball
Ans: B
Feedback:
In children, the spleen is the most frequently injured organ when there is abdominal
trauma. Frequent causes of injury include skateboard accidents. Injuries to the spleen are
not associated with shooting pool or playing baseball or basketball.
5. Before discharging a school-age child being treated for a snake bite, the nurse instruct
ways to prevent additional bites in the future. Which statement indicates that teaching
provided to this child has been effective?
A) “I should wear long pants when out of doors.”
B) “I should look at rocks before touching them.”
C) “I should poke a snake with a stick before touching it.”
D) “I should spray a snake with water before picking it up.”
Ans: B
Feedback:
Common safety rules to avoid snake bites include being aware that snakes like to sit in
the sun on warm rocks. The child should look at a rock before touching it to prevent a
snake bite. Wearing long pants will not necessarily prevent snake bits. Snakes should
not be poked or sprayed with water. Snakes should be identified in underbrush and
under rocks. Snakes should also be identified by sound and markings.
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6. A school-age child comes into the emergency clinic complaining of knee pain that
started while playing soccer. What will the nurse most likely observe when assessing
this child's knee?
A) Edema
B) Erythema
C) Contusions
D) Mottled skin
Ans: A
Feedback:
Participation in sports such as soccer is a frequent cause of knee injuries in children and
usually involves the ligaments surrounding the knee. Immediately after the injury, the
child reports severe pain in the knee, and localized edema becomes evident. Erythema,
contusions, and mottled skin are not associated with a knee injury caused by
participation in a sport.
7. A preadolescent child sprains the right ankle while inline skating. What should the nurse
instruct the child and parents about the care that the child will need at home? (Select all
that apply.)
A) Apply ice pack for 20-minute intervals.
B) Apply ice pack on the ankle for 4 to 7 days.
C) Keep wrapped in an elastic bandage.
D) Remind to use crutches to walk for 3 to 4 days.
E) Apply heat to the ankle beginning the first day after injury.
Ans: A, B, C, D
Feedback:
Interventions to help with a sprain include applying ice pack for 20-minute intervals,
applying ice pack on the site for 4 to 7 days, wrapping with an elastic bandage, and
using crutches to walk for 3 to 4 days after the injury. Heat is not applied to a sprain.
8. A child with extensive burns is permitted to eat. Which nutrient should the nurse ensure
is of a high amount when the child's meals are being prepared?
A) Fats
B) Protein
C) Minerals
D) Carbohydrates
Ans: B
Feedback:
To supply adequate calories for increased metabolic needs and spare protein for repair
of cells after a burn injury, the diet is high in calories and protein. The diet does not
need to be high in fat, minerals, or carbohydrates.
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9. The nurse calculates that a child with a burn injury is to receive 3,600 ml of intravenous
fluid over the next 24 hours. How much of this fluid should the nurse provide to the
patient during the first 8 hours?
A) 900 ml
B) 1,200 ml
C) 1,800 ml
D) 2,700 ml
Ans: C
Feedback:
Fluid is administered rapidly for the first 8 hours after the injury or half of the 24-hour
load and then more slowly for the next 16 hours or the second half. If the child is to
receive 3,600 ml of fluid over 24 hours, half of the amount, or 1,800 ml, should be
infused over the first 8 hours. The remaining 1,800 ml should be infused over the next
16 hours.
10. The nurse notes that a child with a burn injury is prescribed daily debridement. What
should the nurse instruct the child and parents about the purpose of this treatment?
A) Relieves pain
B) Prevents infection
C) Maintains mobility of extremities
D) Decreases the need for skin grafts
Ans: B
Feedback:
Debridement is the removal of necrotic tissue on which microorganisms could thrive
from a burned area to reduce the possibility of infection. Debridement does not relieve
pain but rather is a very painful procedure. Debridement does not influence extremity
mobility. The need for skin grafts depends on the depth of the burned tissue.
11. The school nurse is planning a presentation to be given during the next parent/teacher
conference to include the 2020 National Health Goals to prevent unintentional injuries
in children. What should the nurse include in this presentation? (Select all that apply.)
A) Legal aspects of child abuse
B) Recognize signs of self-injury
C) Provide information on home safety
D) Ways to determine intentional injuries
E) Emphasize safety with sports activities
Ans: B, C, D, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to prevent
unintentional injuries in children by providing counseling on safety precautions to
parents and children and always help assess whether injuries were unintentional or could
be child maltreatment or self-injury. The legal aspects of child abuse would not be
appropriate for this presentation.
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12. The nurse is preparing to administer activated charcoal to a 4-year-old child who
accidentally ingested a family member's heart medication. What should the nurse do to
reduce the discomfort from this treatment?
A) Insert a nasogastric tube.
B) Mix the charcoal in milk.
C) Obtain an order for an indwelling urinary catheter.
D) Bring an intravenous infusion for fluid replacement.
Ans: A
Feedback:
Activated charcoal absorbs toxic substances that have been swallowed to prevent them
from being absorbed by the stomach. The drug is provided as a powder that must be
mixed with water, and not milk, and administered orally or through a nasogastric tube.
The solution feels gritty and tastes disagreeable, so it may be difficult to swallow. A
nasogastric tube will help decrease the child's discomfort when taking the medication.
This medication does not require an indwelling urinary catheter or intravenous infusion
for fluid replacement.
13. A school-age child is brought to the emergency department after being hit in the mouth
with a baseball bat during Little League. The child has lost two deciduous teeth, and one
permanent front tooth is loose. What care should the nurse prepare to provide to this
patient? (Select all that apply.)
A) Administer prescribed oral antibiotic.
B) Wash the deciduous teeth with saline to be wired into place.
C) Instruct the parents and the child that the jaw will need to be wired shut.
D) Explain that an X-ray may be done to make sure that the jaw was not fractured.
E) Explain that a chest X-ray will be done to make sure that other teeth are not in the
lungs.
Ans: A, D
Feedback:
With dental fractures, deciduous teeth may not be replaced. If the blow to the teeth was
extensive, an X-ray may be done to ensure that the upper or lower jaw is not fractured.
The patient will be prescribed an oral antibiotic. The jaw does not need to be wired shut
unless it is fractured. A chest X-ray would be done if the missing teeth are
unaccountable.
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14. The nurse is caring for a preschool-age child who survived near drowning. Which
interventions should the nurse plan to promote optimum respiratory functioning for this
patient? (Select all that apply.)
A) Turn and reposition every 2 hours.
B) Administer antibiotics as prescribed.
C) Auscultate lung sounds every 2 to 4 hours.
D) Monitor cardiac rhythm and blood pressure.
E) Encourage deep breathing and incentive spirometry every hour.
Ans: A, B, C, E
Feedback:
After a near drowning, the child should be turned every 2 hours. The child is usually
prescribed prophylactic antibiotic therapy to prevent pneumonia. Lung sounds should be
auscultated frequently for adventitious sounds. Deep breathing and incentive spirometry
should be encouraged every hour help to aerate the lungs fully and prevent the
accumulation of fluid, which promotes infection. Monitoring cardiac rhythm and blood
pressure are not interventions specifically for respiratory functioning.
15. A 3-year-old child is brought to the emergency department after swallowing batteries
taken from a grandparent's hearing aids. The parents believe that two batteries were
swallowed. What should the nurse explain to the parents regarding the care that the
child will need at this time?
A) Activated charcoal so that the child will vomit the batteries
B) Preparation for an emergency endoscopy to remove the batteries
C) Oxygen to ensure that the child's blood is thoroughly oxygenated
D) Emergency intubation to ensure that the child has an adequate airway
Ans: B
Feedback:
Objects that do not digest such as batteries need to be removed by endoscopy as soon as
possible because they can lead to bowel perforation or volvulus from the acid within the
object. Activated charcoal is used for accidental poisoning. The child is not
demonstrating signs of respiratory distress and will not need oxygen or emergency
intubation.
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Chapter 53 Nursing Care of a Family When a Child Has a Malignancy
1. The nurse is caring for a 4-year-old child with acute lymphocytic leukemia (ALL). Why
should the nurse assess this child's temperature using the axillary route instead of a
rectal temperature?
A) The child has anemia.
B) The child is prone to diarrhea.
C) The child has a low platelet count.
D) The child has a low white blood cell count.
Ans: C
Feedback:
Because platelet production is limited in children with leukemia, children are extremely
prone to hemorrhage. Gastrointestinal bleeding can occur. An axillary temperature is not
taken because the child has anemia, prone to diarrhea, or has a low white blood cell
count.
2. A female patient asks the nurse why she is always asked if she is pregnant before having
an X-ray. What should the nurse explain to the patient?
A) “Radiation to a fetus can cause a malignancy.”
B) “It is just something that we are expected to do.”
C) “It identifies how much radiation your body can stand.”
D) “It determines how long you can be in the radiation room.”
Ans: A
Feedback:
Radiation during intrauterine life is a documented cause of leukemia. Radiation of the
thyroid in infancy is known to cause thyroid cancer later in life. Asking a female patient
about pregnancy status is not something that a nurse is expected to perform. Asking a
female patient about being pregnant is not done to determine how much radiation the
body can stand or determine how long the patient can be in the radiation room.
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3. The nurses caring for children on an oncology unit are planning an open-house
presentation on cancer prevention actions to support the 2020 National Health Goals.
Which topics should the nurses include in their presentation? (Select all that apply.)
A) Teaching testicular self-examination
B) The need to take vitamin supplements every day
C) The importance of getting adequate rest and daily exercise
D) Explaining the reasons to avoid excessive sun exposure
E) The importance of frequent health assessments to identify the symptoms of
leukemia
Ans: A, D, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals for cancer
prevention in children by careful history taking at health assessments to reveal the
symptoms of leukemia and by active teaching of self-screening measures such as
testicular examination and preventive measures such as avoiding excessive sun
exposure. Vitamin supplementation, rest, and exercise are not identified as actions to
prevent cancer in children.
4. A child with leukemia is receiving methotrexate for therapy. Which nursing diagnosis
should the nurse use to best guide this patient's care at this time?
A) Impaired oral mucous membrane related to effects of chemotherapy
B) Risk for impaired mobility related to depressant effects of methotrexate
C) Excess fluid volume related to effect of methotrexate on aldosterone secretion
D) Risk for self-directed violence related to effect of methotrexate on central nervous
system
Ans: A
Feedback:
Mucositis or ulcers of the gum line and mucous membranes of the mouth is a frequent
effect of antimetabolic drugs. This is the diagnosis that would have the highest priority
for the patient's care at this time. Methotrexate does not impair mobility, impact
aldosterone secretion, or cause adverse effects to the central nervous system.
5. A child with leukemia is prescribed to receive ondansetron hydrochloride (Zofran) 0.15
mg/kg intravenously prior to receiving the first dose of chemotherapy. The child weighs
55 lb. How many milligrams of the medication should the nurse provide to the child?
(Numeric value only. Calculate to the nearest tenth decimal point.)
Ans: 3.8 mg
Feedback:
The nurse needs to first determine the child's weight in kilograms by dividing 55 lb by
2.2 or 55 / 2.2 = 25. Then the nurse should multiply the prescribed dose of 0.15 mg by
the child's weight or 0.15 mg × 25 kg = 3.75. After rounding, the nurse should provide
the patient with 3.8 mg of the medication prior to receiving chemotherapy.
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6. The nurse is preparing the medication leucovorin to provide to a child who is currently
receiving methotrexate for a brain tumor. What should the nurse explain to the child and
parents regarding the purpose of this medication?
A) It will encourage bone marrow to build new cells after methotrexate therapy.
B) It helps methotrexate enter leukemia cells the same as insulin helps glucose enter
cells.
C) It is an experimental drug to ensure resistance to infection during methotrexate
therapy.
D) It prevents methotrexate that is not incorporated into leukemia cells from entering
normal cells.
Ans: D
Feedback:
A drug such as leucovorin, often called leucovorin rescue, may be administered after
systemic methotrexate to neutralize its action and protect normal cells from the effect of
the drug. Leucovorin is not used to encourage the growth of new cells in the bone
marrow. It does not facilitate the use of methotrexate in the cells. Leucovorin is not an
experimental drug used to improve resistance to infection.
7. A child being treated for leukemia is diagnosed with neutropenia. What should the nurse
instruct the parents and child to prevent infections? (Select all that apply.)
A) Avoid large crowds.
B) Inspect the skin daily for scratches or scrapes.
C) Increase the intake of fresh fruits and vegetables.
D) Remove house plants, flowers, and goldfish from the home environment.
E) Stay away from people who have obvious colds, rashes, or other infections.
Ans: A, B, D, E
Feedback:
Strategies to prevent infections in a child with neutropenia include avoiding large
crowds; inspecting the skin daily for scratches or scrapes; removing house plants,
flowers, and goldfish from the home environment; and staying away from people who
have obvious colds, rashes, or other infections. The child's intake of fresh fruits and
vegetables should be limited because this could be a source for bacteria.
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8. The nurse is concerned that a child receiving vincristine is developing an adverse
reaction to the medication. What did the nurse most likely assess in the patient?
A) Tooth pain
B) Numb fingertips
C) Reduced hearing
D) Bright red cheeks
Ans: B
Feedback:
The use of vincristine can cause specific neurologic symptoms of weakness, tingling,
and numbing of the extremities and sometimes the inability to walk because of loss of
ankle support. This medication does not cause tooth pain, reduced hearing, or bright red
cheeks.
9. The nurse is planning outcomes for an adolescent male diagnosed with Hodgkin disease.
Which outcome should the nurse use to address feelings of powerlessness with the
disease?
A) The patient attends recommended appointments.
B) The patient reduces the frequency of extracurricular activities.
C) The patient cuts back the number of hours worked after school.
D) The patient spends time with elderly grandparents and other family members.
Ans: A
Feedback:
An outcome that would support feelings of powerlessness would be the patient attends
recommended appointments. Reducing extracurricular activities, reducing the number of
work hours, and spending time with elderly grandparents and other family members do
not support feelings of powerlessness.
10. The mother of a high school football player diagnosed with osteosarcoma of the femur
is angry because she did not want him to play football. Which health teaching point
should the nurse include in the teaching plan for the patient and mother?
A) Tumor growth is more related to a dislike of milk.
B) Osteosarcoma often follows trauma, such as a football injury.
C) Football injuries do not contribute to the development of a tumor.
D) The patient can expect some discoloration of his leg following chemotherapy.
Ans: C
Feedback:
To prevent the adolescent and parents from thinking that the patient caused the tumor,
the nurse should explain that trauma did not cause the process. A football injury merely
called attention to the leg where a malignant process was at work. Osteosarcoma is not
caused by a dislike of milk. There is no expectation of skin color changes when
receiving chemotherapy for osteosarcoma.
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11. The nurse is completing the health history of a 6-month-old baby with retinoblastoma
with the child's parents. Which symptom should the nurse expect that the parents have
observed?
A) One pupil appears white.
B) The infant tugs and pulls at one ear.
C) The infant's eye appears to be protruding.
D) The infant always keeps her eyes tightly closed.
Ans: A
Feedback:
On examination, the child's pupil of the affected eye appears white because the red
reflex is absent. Some might describe this symptom as a “cat's eye.” Ear tugging, eye
protrusion, and keeping the eyes closed are not manifestations of retinoblastoma.
12. The nursing is planning care for a child recovering from neck surgery for
rhabdomyosarcoma. Which outcome suggests the best long-term prognosis for this
patient?
A) The child tolerates chemotherapy to treat the tumor and on the neck and lungs.
B) The child tolerates radiation for neck tumor and tumor found in the colon and
liver.
C) The child tolerates chemotherapy provided after complete removal of the neck
tumor.
D) The child tolerates chemotherapy every 4 weeks for 24 months to eradicate
inoperable tumor.
Ans: C
Feedback:
A child's prognosis depends on the size of the tumor and whether metastasis was present
at the time of initial diagnosis. If the entire tumor was removed and no lymph node
metastasis has occurred, the chances are as high as 80% that the tumor will not recur. If
some of the tumor had to be left because of its size or location, the chance of recurrence
rises to about 50%. If metastasis to the lungs or bone was present at the time of the
initial diagnosis, the prognosis drops to about 20% of children with long-term survival.
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13. While assessing a school-age child with a brain tumor after morning report, the child
has an episode of projectile vomiting. What should the nurse do to help the child?
A) Hold the child's breakfast tray.
B) Administer an antiemetic as prescribed.
C) Provide a cool compress for the forehead.
D) Provide a snack until the breakfast tray arrives.
Ans: D
Feedback:
In a child with a brain tumor, vomiting most commonly occurs on arising. The child
with a brain tumor is not usually nauseated and will eat immediately afterward. The
vomiting pattern occurs morning after morning. Vomiting eventually will become
projectile. The nurse should provide the child with a snack until the morning breakfast
tray arrives. The child will be hungry and can eat after an episode of projectile vomiting.
The child does not need an antiemetic or a cool compress.
14. The nurse is preparing to post a sign above the crib of an infant with a Wilms tumor.
Which statement should the nurse post immediately?
A) “Do not palpate abdomen.”
B) “No intramuscular injections.”
C) “No milk or milk products allowed.”
D) “No blood sampling in lower extremities.”
Ans: A
Feedback:
It is important that the child's abdomen not be palpated any more than is necessary for
diagnosis because handling appears to aid metastasis. Place a sign reading “No
Abdominal Palpation” over the child's crib to help prevent this. Intramuscular injections,
milk products, or blood sampling in the lower extremities are not contraindicated for
this health problem.
15. The nurse is preparing to send a child with cancer for a radiation treatment. Which
medication should the nurse provide to premedicate the child for this procedure?
A) Analgesic
B) Antiemetic
C) Antipyretic
D) Antineoplastic
Ans: B
Feedback:
Radiation has systemic effects. Radiation sickness that includes nausea and vomiting is
the most frequently encountered systemic effect. It also occurs to some extent as a result
of the release of toxic substances from destroyed tumor cells. To counteract this, a child
is prescribed an antiemetic before each procedure. The patient does not need an
analgesic, antipyretic, or antineoplastic agent prior to receiving a radiation treatment.
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Chapter 54 Nursing Care of a Family When a Child Has an Intellectual or Mental
Health Disorder
1. The mother of a school-age child is distraught over the ongoing oppositional behavior
demonstrated by the child at home and at school. Which nursing diagnosis should the
nurse select as appropriate for the child and family at this time?
A) Risk for self-directed violence related to impulsivity
B) Situational low self-esteem related to lack of successful coping strategies
C) Impaired social interaction related to short attention span and distractibility
D) Interrupted family processes related to inability of child to follow instructions
Ans: D
Feedback:
Oppositional defiant disorders consist of long-term hostile, negativistic, or defiant
behaviors that result in disturbed functioning in academic and social domains. Children
typically have difficulty controlling their temper; such anger is often directed at an
authority figure. The disorder develops most frequently in late preschool or early school
age. The diagnosis most appropriate for this child and parent is interrupted family
processes. There is no evidence to suggest that the child is at risk for self-directed
violence, low self-esteem, or impaired social interaction.
2. An extremely thin preadolescent is being assessed by the nurse. Which patient statement
should the nurse identify as being consistent with that of a person with anorexia
nervosa?
A) “I'd like to grow up to be a model.”
B) “I'd like to gain weight but just can't.”
C) “I feel chubby no matter what I wear.”
D) “I'm afraid that someone is poisoning my food.”
Ans: C
Feedback:
Characteristics of a child with anorexia nervosa include a severely distorted body image
with an intense fear of gaining weight or becoming fat. The goal to be a model is not
consistent with that of anorexia nervosa. The inability to gain weight is not a
characteristic of anorexia nervosa. The fear of food being poisoned is a characteristic of
paranoid behavior.
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3. The community health nurse is working with the school district to provide an
educational program on the 2020 National Health Goals to address cognitive and mental
health disorders in children. Which topics should the nurse emphasize in this program?
(Select all that apply.)
A) Stress-reduction techniques
B) Manifestations of stress in children
C) Recognizing depression in children
D) Strategies for oppositional behavior
E) Nutrition and adequate weight gain
Ans: A, B, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to address cognitive
and mental health disorders in children by educating parents about nutrition and
inadequate weight gain; educating families about ways to reduce stress; and identifying
children in school and health care settings who demonstrate a high level of stress,
depression, or other symptoms of mental illness.
4. The nurse is caring for a 6-month-old infant who is diagnosed with rumination disorder.
For which additional health problems should the nurse plan to assess this patient?
A) Cardiac disorders
B) Respiratory problems
C) Cognitive development
D) Urinary tract malformation
Ans: C
Feedback:
A rumination disorder is the act of regurgitating and then reswallowing previously
digested food. Even though it is rare, it usually affects infants between the ages of 3 and
12 months and is seen most often in children who are cognitively challenged.
Rumination disorder is not associated with cardiac, respiratory, or urinary tract
problems.
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5. The nurse is preparing teaching materials for the parents of a child with encopresis.
What information should the nurse emphasize during this teaching?
A) Not punishing the child for the condition
B) Necessity for giving 4 to 6 tablespoons of Kaopectate per day
C) Need for keeping the child close to bathroom facilities at all times
D) Importance of cleaning the child immediately after an accident occurs
Ans: A
Feedback:
Encopresis is the inappropriate passage of stool in places not culturally appropriate for
that purpose. Parents should not punish the child for encopresis but rather to pay as little
attention as possible to bowel accidents and to give praise for days when encopresis
does not occur. The child does not need Kaopectate every day. The child does not need
to be close to bathroom facilities at all times. The child does not experience diarrhea
soiling after accidents would not be of a high priority for teaching.
6. The mother of an 11-month-old infant is concerned that the child is developing autism
because the child likes to rock on the hands and knees in the crib before going to sleep.
What should the nurse respond to this mother's concern?
A) “Rocking means the child is hungry.”
B) “Rocking is abnormal behavior associated with autism.”
C) “Rocking can be seen as a form of self-stimulation.”
D) “Be sure to pad the crib so the child does not hurt the head while rocking.”
Ans: B
Feedback:
Rocking is hypothesized as being a form of self-stimulation. The child with autism will
engage in constant body rocking. Because the child likes to perform body rocking
before going to sleep and not constantly, it is more likely being used by the child as a
form of self-stimulation. Rocking does not mean that the child is hungry. Rocking is not
only seen in autism. The mother did not express concern that the child is banging the
head on the crib while rocking so padding the crib might not be appropriate at this time.
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7. The nurse is planning educational materials to help the parents care for a cognitively
challenged child at home. What should the nurse include in this teaching? (Select all
that apply.)
A) Provide generous praise.
B) Reduce environmental stimulation.
C) Scold for not learning abstract concepts.
D) Break a large task down into smaller steps.
E) Demonstrate the skill that the child is to perform.
Ans: A, B, D, E
Feedback:
Guidelines for teaching the cognitively challenged child include providing generous
praise, reducing environmental stimulation, breaking a task down into smaller steps, and
demonstrating the skill to be performed. Cognitively challenged children may have
difficulty with learning abstract concepts and should not be scolded.
8. The community nurse is visiting a family with a mildly cognitively challenged child at
home. Which observation indicates that the family is adjusting to this child's learning
capacity?
A) Older sibling teases the child and uses the term “dummy.”
B) Father tells the child to play with a toy while the adults talk.
C) Parents support and engage the child in family conversation.
D) Mother tells the child to stop making a mess on the kitchen table.
Ans: C
Feedback:
About 85% of children who are cognitively challenged have an IQ of 50 to 70 and may
be referred to as “educable” by a school system. During early years, these children learn
social and communication skills and are often not too distinguishable from average
infants or toddlers. The parent's behavior of supporting and engaging the child in family
conversation indicates that the family is adjusting to the child's learning capacity.
Teasing the child and calling names indicates intolerance of the child's learning
capacity. Telling the child to play while the adults talk or scolding for making a mess
indicate that the family is not adjusting to the child's learning capacity.
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9. The nurse suspects that a child is demonstrating signs of attention deficit hyperactivity
disorder (ADHD). What behavior did the nurse most likely assess in this child?
A) Unrealistic fears
B) A lack of concentration
C) Persistent disobedience
D) A lack of affection for others
Ans: B
Feedback:
Attention deficit hyperactivity disorder (ADHD) is characterized by three major
behaviors: inattention, impulsiveness, and hyperactivity. Inattention or a lack of
concentration makes children become easily distracted and often may not seem to listen
or complete tasks effectively. Unrealistic fears, persistent disobedience, and a lack of
affection for others are not characteristics of ADHD.
10. A child with attention deficit hyperactivity disorder (ADHD) is prescribed
methylphenidate hydrochloride (Ritalin). What should the nurse instruct the parents
regarding an adverse effect of this medication?
A) Anorexia
B) Sleepiness
C) Garbled speech
D) Rapid increase in height
Ans: A
Feedback:
An adverse effect of methylphenidate hydrochloride (Ritalin) is anorexia. Sleepiness
and garbled speech are not adverse effects of this medication. Children taking this
medication can develop growth suppression and not accelerated growth in height.
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11. For which child's behavior should the nurse identify as having characteristics of
separation anxiety disorder?
A) An 8-month-old who cries when left with strangers
B) A 7-year-old who withdraws from contact with all strangers
C) An 8-year-old who will not stay overnight at a friend's house
D) A 10-year-old who complains of headaches if he has a test in school
Ans: C
Feedback:
Separation anxiety is considered a disorder when an older child shows excessive anxiety
about separation or the possibility of separation from parents. They experience acute
distress and perhaps frequent nightmares about separation and, when separated, show
symptoms of nausea or vomiting or crying to such a degree it prevents them from
visiting at friends' houses. For an 8-month-old, crying when being left with strangers is
a normal behavior. A 7-year-old who withdraws from contact with strangers might have
been instructed to do this as a form of safety or might be shy. A 10-year-old who
complains of headaches when a test is scheduled for school is demonstrating some other
type of behavior. Separation anxiety would not occur just when a test is scheduled in
school.
12. The nurse is caring for a 12-month-old child diagnosed with autistic disorder. What
information from the mother during the health history should the nurse identify as being
consistent with the health problem?
A) The child speaks in complete sentences.
B) The child sleeps at least 12 out of every 24 hours.
C) The child responds warmly to the father but not to the mother.
D) The child constantly stares at a rotating wheel on the crib mobile.
Ans: D
Feedback:
A manifestation of autistic disorder is an abnormal response to sensory stimuli such as
staring at a rotating wheel on the crib mobile. A child with autistic disorder will
demonstrate repetitive words and failure to develop social relationships. The number of
hours of sleep is not used to help identify autistic disorder.
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13. After an assessment, the nurse believes that a school-age child is at risk for developing a
mental health disorder. Which assessment data will the nurse use to plan the care for this
child? (Select all that apply.)
A) Parents recently divorced
B) Father unemployed and mother not always home
C) Learning to play the clarinet in music class in school
D) Expected to care for younger siblings while mother sleeps
E) History of multiple injuries obtained from a motor vehicle crash
Ans: A, B, D, E
Feedback:
Various factors have been associated with an increased risk for mental health disorders
in children, including trauma, poverty or neglect, difficult temperament or attachment
problems, medical illness, or major losses to the family such as divorce. Learning to
play the clarinet in school has not been associated with an increased risk for mental
health disorders in children.
14. A school-age child is admitted to the mental health unit with the diagnosis of
schizophrenia. What manifestations of this disorder should the nurse recognize when
assessing this patient? (Select all that apply.)
A) Paranoia
B) Quiet but responsive
C) Talking about suicide
D) Illogical speech pattern
E) Auditory hallucinations
Ans: A, D, E
Feedback:
Children with schizophrenia experience paranoia, hallucinations, and illogical speech
patterns. Quiet but responsive is not a characteristic of schizophrenia. Talking about
suicide is a characteristic of depression.
15. The nurse suspects that a school-age child has Tourette syndrome. What did the nurse
most likely assess in this patient?
A) Flat affect
B) Shouting obscenities
C) Playing quietly alone
D) Running wildly in circles
Ans: B
Feedback:
Tourette syndrome is an inherited syndrome of motor and phonic vocal tics. Complex
vocal tics include the repeated use of words or phrases out of context—specifically,
coprolalia or the use of socially unacceptable words such as obscenities. Flat affect,
playing alone, and running wildly in circles are not manifestations of Tourette
syndrome.
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Chapter 55 Nursing Care of a Family in Crisis: Maltreatment and Violence in the Family
1. A 3-month-old infant is diagnosed with failure to thrive. For which cause should the
nurse include interventions when planning care for this patient?
A) A reaction to severe stress
B) Limited calcium metabolism
C) Poor parent–child relationship
D) Interference with gastrointestinal absorption
Ans: C
Feedback:
Failure to thrive is a syndrome in which an infant falls below the 5th percentile for
weight and height on a standard growth chart or is falling in percentiles on a growth
chart. One category of this syndrome occurs because of a disturbance in the parent–child
relationship, resulting in maternal role insufficiency or a nonorganic cause. Failure to
thrive is not caused by a reaction to severe stress, limited calcium metabolism, or
interference with gastrointestinal absorption.
2. The nurse manager of an urban health care clinic is designing a series of presentations
for staff to address the 2020 National Health Goals to reduce child maltreatment and
intimate partner violence. Which topics should the manager include in these
presentations? (Select all that apply.)
A) Caring for victims of rape
B) Indications of child neglect
C) Recognizing victims of violence
D) Environments where rape occurs
E) Manifestations of child maltreatment
Ans: B, C, E
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to reduce child
maltreatment and intimate partner violence by identifying children or women in school
or health care agency settings who have been maltreated, neglected, or a victim of
violence. Caring for rape victims and environments where rape occurs are not strategies
to achieve the 2020 National Health Goals to reduce child maltreatment and intimate
partner violence.
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3. At the completion of a health interview, the nurse is concerned that a newborn is at risk
for maltreatment. Which observation caused the nurse to come to this conclusion?
A) Mother does not look at the baby.
B) Mother helps the nurse loosen the baby's clothing for a physical examination.
C) Mother explains that the husband helps with feeding the baby during the night.
D) Mother quickly changes a dirty diaper and uses personal supplies to cleanse the
child.
Ans: A
Feedback:
The mother's inability to establish eye contact, or maintain a direct en face position with
the baby, can indicate the potential for child maltreatment. Helping the nurse loosen
clothing for an examination, identifying someone to help with child care, and prompt
attention to the baby's needs when changing a soiled diaper indicate the mother is
bonding with the child, and the child is not at risk for maltreatment.
4. When beginning care for a victim of rape, the nurse asks the patient to “talk about what
happened” to her. For which nursing diagnosis is the nurse using this approach?
A) Anxiety related to recent rape
B) Fear related to repeated episodes of maltreatment
C) Disabling family coping related to recent rape of family member
D) Risk for other-directed violence related to admitted poor self-control
Ans: A
Feedback:
One need of any victim after a violent act is to talk about what happened because a
person who can describe an incident can also begin to “put a fence around” or bring the
event down from “something terrible has happened,” a situation which leaves the person
with a continuing high anxiety level, to “this specific thing has happened,” a situation
that allows the traumatic event to be examined and managed. Asking the victim to
describe the incident to with an introduction such as “Most people find it helps to talk
about what happened to them” helps the victim begin to put a fence around the incident.
The nurse is not asking the patient to “talk about what happened” because of fear of
maltreatment, disabling family coping related to the rape, or risk for violence related to
poor self-control.
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5. The nurse is visiting the home of a family with a previous history of physical neglect.
Which observation indicates that interventions have not been successful?
A) The mother feeds the children a total vegetarian diet.
B) The father encourages male children to play high school football.
C) The mother worries that immunizations will be painful for the children.
D) The father allows the children to stay home from school whenever they desire.
Ans: D
Feedback:
Not requiring a child to attend school may be interpreted as neglect. Following a
vegetarian diet, encouraging participating in sports, and concern about immunization
discomfort do not indicate that interventions to address physical neglect have not been
successful.
6. While making a home visit, the nurse suspects that a child is experiencing psychological
maltreatment. What did the nurse observe in the home?
A) Scolding one child for playing with matches
B) Belittling the child in front of the nurse and other siblings
C) Punishing one child for crossing the street without assistance
D) Asking one child to perform a song on the piano for the nurse
Ans: B
Feedback:
Psychological maltreatment includes constant belittling a child. Children who are
psychologically maltreated this way are likely to have difficulty becoming emotionally
confident adults. This type of maltreatment is the most difficult form of maltreatment to
detect because it may occur only in the home. Scolding for using matches, punishment
for crossing the street without assistance, and asking to perform a song on the piano are
not observations that support psychological maltreatment.
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7. The mother of a toddler experiencing stomach pain insists that the child be admitted to
find out the cause of the pain. The child has been in the emergency room three other
times in the past 6 months for the same complaint. What other information should alert
the nurse to investigate the situation further?
A) The mother is a single parent.
B) The mother is in nursing school.
C) The child has a 1-year-old sister.
D) The child verbalizes abdominal pain when the mother is not present.
Ans: B
Feedback:
Munchausen syndrome by proxy refers to a parent who repeatedly brings a child to a
health care facility and reports symptoms of illness when the child is well. A parent
might report symptoms such as abdominal pain in a child. Because of these symptoms,
the child is submitted to needless diagnostic procedures or therapeutic regimens. The
parent usually has some degree of medical or child care knowledge obtained through
formal education. Being a single parent, having siblings, and the child verbalizing
abdominal pain when the mother is not present are not indications of this syndrome.
8. The school district is planning an educational program for high school students to
reduce the incidence of rape. When planning this program, which information should
the school nurse include? (Select all that apply.)
A) Carry a weapon or mace at all times.
B) When leaving school after dark, walk on the street.
C) Lock car doors when waiting in it and after parking it.
D) Keep all doors and windows locked when home alone.
E) Avoid taking illegal substances when in social situations.
Ans: B, C, D, E
Feedback:
Guidelines to prevent rape in adolescents include walking on the street when it is dark,
locking car doors when waiting in it and after parking it, keeping all doors and windows
locked when home alone, and avoid talking illegal substances such as Rohypnol when in
social situations. Students should be cautioned about carrying weapons or mace because
these items can be used against them.
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9. Which patient's physical assessment finding of a school-age child should the nurse
question as a potential indication of abuse?
A) A thin, tall appearance
B) A scald burn on the chest
C) A maculopapular rash on the buttocks
D) Linear abrasions on his ankles and wrists
Ans: D
Feedback:
Abrasions or ecchymotic areas on the wrists or ankles may be present if the child was
tied to a bed or against a wall. Being thin and tall is not an indication of abuse. A scald
burn on the chest could have occurred while eating a meal at home. A rash on the
buttocks is not an indication of physical abuse.
10. The nurse visits the foster home of a newborn with failure to thrive syndrome. Which
observation indicates a successful outcome for this child's care?
A) Birth mother has stopped visiting the child.
B) Birth father comes by the home to bring toys.
C) Child eagerly takes a bottle and is gaining weight.
D) Child is crying and has bruises over the lower legs.
Ans: C
Feedback:
A successful outcome for the care of a child with failure to thrive syndrome would be
that the child shows interest in bottle feedings and begins to gain weight. The child
crying and having bruises over the legs could indicate physical abuse or another medical
problem. The mother not visiting the child indicates ongoing psychological issues with
the mother bonding with the child. The father bringing toys does not indicate that the
care of the child has been successful. The father's bonding with the child cannot be
determined by this action of bringing toys.
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11. The nurse gives a preschool-age child two anatomically correct dolls to play with in
efforts to determine if the child has been sexually abused. Which observation indicates
to the nurse that this is a possibility?
A) Child inserts the male doll's penis into the female doll's mouth.
B) Child holds both dolls together to make them walk together holding hands.
C) Child takes off the dolls' clothing, laughs, and then puts the clothes back on.
D) Child holds dolls facing each other and moves the arms so that the dolls hug.
Ans: A
Feedback:
Allowing young children to play with anatomically correct dolls is a common method
for determining whether sexual maltreatment is occurring. The child who is involved in
an incestuous relationship may make the dolls perform a sexual act, such as placing the
male doll's penis into the female doll's mouth. The average reaction of a preschool-age
child who has not been maltreated is to undress the dolls, giggle for a moment or two
about how they look, and then redress or put them aside. Playing with the dolls so that
they hold hands and hug does not indicate that the child has been sexually abused.
12. The nurse in the emergency department is documenting the appearance and care
provided to a victim of rape. Which statement should the nurse include when
documenting this care?
A) Victim has blood stains on both inner thighs.
B) Victim claims to be raped but does not appear fearful or traumatized.
C) Victim handling the incident well by talking with the male police officers.
D) Victim wearing provocative low-cut lace blouse and bra and short skirt with high
heels.
Ans: A
Feedback:
When documenting the care and condition of a victim of rape, the nurse needs to be
certain that statements are accurate and unbiased. The nurse should describe the victim's
appearance in unbiased detail, including the presence and location of injuries. Making a
statement such as “victim claims to be raped but does not appear fearful or traumatized”
is a biased statement. The statement that the victim is handling the incident well by
talking with male police officers and using the word “provocative” when describing the
victim's clothing are biased statements and should not be a part of the medical record.
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13. The nurse decides to spend extra time with a pregnant patient in the prenatal clinic in
efforts to determine if the patient is a victim of intimate partner violence. What caused
the nurse to make this plan prior to assessing the patient?
A) Patient chatting with another patient in the waiting room
B) Patient wearing a long sleeved jacket on a hot summer day
C) Patient periodically looking at a wrist watch to check the time
D) Patient unconsciously rubbing the abdomen while reading a magazine
Ans: B
Feedback:
Pregnant maltreated patients may demonstrate typical behaviors that reveal violence. A
patient may dress inappropriately for warm weather, wearing long-sleeved blouses to
cover up bruises on the neck or arms. A patient who is talking with another patient,
checking the time on a wrist watch, and rubbing the abdomen while reading a magazine
are not behaviors that indicate intimate partner violence.
14. The community nurse is visiting a victim of rape at home. Which observation indicates
that crisis intervention goals have not been met?
A) Husband hopes to meet the rapist in a back alley 1 day.
B) Victim and husband sit with the nurse at the kitchen table and discuss feelings.
C) Victim states that intimate relationship with the husband has resumed without
incident.
D) Husband holds the victim's hand and expresses endearing terms while the victim
smiles.
Ans: A
Feedback:
Goals of crisis intervention for families of rape victims include helping the family be
supportive of the victim, discussing the sexual relationship between partners, and the
partner expressing feelings have not changed. A goal is also to discourage violent
retribution toward the rapist. The husband desiring to meet the rapist in a back alley
indicates that crisis intervention goals have not been met.
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15. During a routine well-child visit, the mother of a preadolescent patient asks the nurse to
explain signs of sexual abuse. The mother is concerned because an older male neighbor
has been making comments and overtly admiring the child when playing outdoors.
What information should the nurse provide to the mother? (Select all that apply.)
A) Child reports abdominal pain.
B) Child has a change in school performance.
C) Child demonstrates anxiety or trouble sleeping.
D) Child does not want to be left alone with a certain adult.
E) Child spends a great deal of time with peer-group friends.
Ans: A, B, C, D
Feedback:
Signs of sexual maltreatment include vague reports of abdominal pain, a change in
school performance, anxiety or trouble sleeping, and not wanting to be left alone with a
certain adult. Spending time with peer-group friends is an expected preadolescent
behavior and is not a sign of sexual maltreatment.
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Chapter 56 Nursing Care of a Family When a Child Has a Long-Term or
Terminal Illness
1. The nurse is caring for an infant born with a congenital anomaly. Which of the
following factors is likely to have the most influence on the mother's ability to cope with
the infant's handicap?
A) The mother's age
B) The gender of the infant
C) The parent's amount of support
D) The fact that this is a mental and not a physical challenge
Ans: C
Feedback:
Availability of support people to help the mother cope with the infant's handicap will
have a major influence. A family that has few close friends and lives some distance
from relatives is apt to have more difficulty adjusting to illness in a child than a family
that has close support people. People who can locate secondary support systems in their
community usually do better than parents who are without these resources. The mother's
age, gender of the infant, and type of handicap will not have the most influence on the
mother's ability to cope with the infant's needs.
2. The hospice nurse is planning a community program that emphasizes the 2020 National
Health Goals to reduce long-term illness and early death in children. Which information
should the nurse include in this program? (Select all that apply.)
A) Strategies to prevent unintentional injury
B) Seeking early prenatal care when pregnant
C) Following recommended immunization schedules
D) Supporting childhood physical activity expectations
E) Following recommended dietary intake requirements
Ans: A, B, C
Feedback:
Nurses can help the nation achieve the 2020 National Health Goals to reduce long-term
illness and early death in children by educating women to seek care during pregnancy so
that congenital anomalies are less frequent and to teach unintentional injury prevention
and the importance of immunizations so unintentional injuries and infectious diseases
that can lead to long-term illness can be reduced. Physical activity expectations and
dietary intake requirements are not strategies to achieve the 2020 National Health Goals
to reduce long-term illness and early death in children.
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3. The community nurse is caring for a family who has a child with a long-term illness. At
which point in life should the nurse anticipate the parents having the least difficult time
accepting the child's condition?
A) On the child's first birthday
B) The day the child starts kindergarten
C) The day the child is toilet trained
D) The day the child would have graduated college
Ans: D
Feedback:
A child's illness usually appears to be more acute at times when the child would
normally reach developmental milestones. When the child does not reach these
traditional milestones, it reminds parents about their child's illness in a particularly
painful way. The first birthday, starting kindergarten, and being toilet trained are
momentous occasions for families raising children. The family may or may not view
attending college as a priority.
4. The parents of a school-age child are informed that their child has muscular dystrophy
and will be wheelchair bound going forward. Which nursing diagnosis should the nurse
identify as appropriate for the parents at this time?
A) Hopelessness related to steady progression of child's disease
B) Interrupted family processes related to recent diagnosis of chronic illness in a
child
C) Decisional conflict related to treatment options and choice of setting for child's
final care
D) Risk for delayed growth and development related to lack of age-appropriate
stimulation because of disability
Ans: B
Feedback:
Because the parents are just learning of the diagnosis of muscular dystrophy, this news
will interrupt family processes. There is no enough information to determine if the
parents are hopeless. The child is not diagnosed with a terminal illness. There is no
enough information to determine if the child is at risk for delayed growth and
development.
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5. The parents of a 6-year-old have just been told that their child will die shortly. At which
age does the nurse realize that children are capable of understanding death?
A) 3 years
B) 6 years
C) 9 years
D) 12 years
Ans: C
Feedback:
As children near 8 or 9 years of age, they begin to appreciate that death is permanent.
Younger children are not able to conceptualize the permanence of death. A 12-year-old
child is able to conceptualize the permanence of death.
6. A child who knows about a terminal disease tells the nurse of plans to recover and
become a doctor to cure everyone in the whole world. What is the child demonstrating
to the nurse?
A) Anxiety about the illness
B) Bargaining stage of grief
C) Immature magical thinking
D) Poor opinion of the care received
Ans: B
Feedback:
Bargaining, a stage of the grief process, is attempting to work out a deal to prevent death
from occurring. This child is not demonstrating anxiety, immature thinking, or a poor
opinion of the care that has been received.
7. A terminally ill child is awake at 2 AM and continues to put on the call light. What
should the nurse do regarding this child's behavior?
A) Provide with a sleeping aid.
B) Encourage the child to sleep.
C) Sit with the child until sleep comes.
D) Put on the television and dim the lights.
Ans: C
Feedback:
Many children assume that they will die at night. A child may talk more freely at night
about fears or an unfulfilled life ambition than during the day. Children may also be
more frightened at night and enjoy having someone sit beside them until they fall
asleep. The nurse should not provide with a sleeping aid. Encouraging the child to sleep
will not meet the child's needs at this time. Putting on the television with dim lights in
the room will not meet the child's needs at this time.
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8. The nurse is caring for a preschool-age child who is aware of impending death. What
behavior should the nurse expect the child to demonstrate at this time?
A) Outbreaks of anger
B) Verbalization of feelings
C) Bargaining for another chance
D) Fear of being separated from parents
Ans: D
Feedback:
Preschoolers fear separation. If able to grasp the concept of dying, this child's major
worry is being alone and separated. These children may need someone to stay with them
constantly to reassure them that they are loved and people are caring for them. Anger,
verbalization of feelings, and bargaining are not behaviors typically associated with a
preschool age-child who is facing death.
9. The mother of a terminally ill child stays with the child day and night. Which statement
indicates that the mother is in the chronic sorrow of depression stage?
A) “I will never accept that my child is dying.”
B) “I know that there is nothing that can be done for my child.”
C) “There must be another doctor somewhere than can help my child.”
D) “I will go to church every week if this will keep my child from dying.”
Ans: A
Feedback:
In the stage of depression, parents begin to face what is happening. They feel sad and
unprotected. Some parents never reach the stage of acceptance and will always remain
in the chronic sorrow of the depression stage. Saying that the child's dying will never be
accepted indicates the chronic sorrow of depression stage. Knowing that nothing can be
done for the child is acceptance. Looking for another doctor to help the child is the stage
of anger. Going to church every week to prevent the child from dying is bargaining.
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10. The nurse is planning care to help young parents adjust to their newborn's long-term
illness. Which assessment findings about the parents will help the nurse plan for their
care? (Select all that apply.)
A) Parents belong to a local church.
B) Parents have strong ties with their parents and siblings.
C) Parents are strong in their marriage and frequently hold hands.
D) Parents state issues with having to spend time at the hospital instead of working.
E) Parents are overheard discussing the cost of the medical care and if insurance will
cover it.
Ans: A, B, C
Feedback:
Factors that ease parental adjustment to a child's long-term illness include having a
strong religious faith, having a good relationship with their parents, having support
people available such as siblings, and having a good marital bond. Having concerns
about missing work and having enough money for medical care are not findings that
will help the parents adjust to their newborn's long-term illness.
11. During a child's last stage of dying, the parents ask if the child is able to hear. What
should the nurse respond to the parents?
A) “No, now that she is semicomatose, she is unable to hear you.”
B) “No one really knows, so it is a good idea not to speak too loudly.”
C) “Yes, she is able to hear and fully comprehend everything that is said.”
D) “Yes, she can hear and may also understand most of what is being said.”
Ans: D
Feedback:
A loss of consciousness occurs as children grow closer and closer to death; although,
they may remain perfectly alert until seconds before death. Because hearing is one of
the last senses lost, the nurse may need to remind family members and other health care
personnel that the child may not be able to respond but may be able to hear. Continue to
explain procedures to unconscious children as if they were conscious because they
undoubtedly do hear. Never make any comment in the child's presence that would not
be made if the child were alert.
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12. The nurse notes that a chronically ill child has not been seeing the health care provider
for several months, although monthly checkups and blood work are needed to help
maintain the illness. What should the nurse realize as a reason for the child missing
appointments?
A) The parents have been too busy to bring the child.
B) The family does not have the money to pay for multiple visits.
C) The child is afraid of having the blood drawn, so the parents do not bring him.
D) The parents are having a difficult time grieving with the idea of the child's illness.
Ans: D
Feedback:
Most parents of a chronically ill child adhere well to instructions and keep health care
appointments consistently. Sometimes, however, parents do not follow this pattern. This
inability to adhere usually is related to their stage of adjustment to the illness. As long as
denial, anger, bargaining, or depression is functioning, coming in for health care or
evaluation is viewed as a major demand. Each visit is more of a reminder of the child's
illness than a time of reassuring health assessment. This behavior does not indicate that
the parents are too busy. There is no enough information to determine if the visits are
cost prohibitive for the family. There is no enough information to determine if the child
is afraid of having blood tests performed.
13. The parents of a terminally ill child do not want the child dying in the hospital. What
can the nurse suggest to help these parent's needs?
A) Admit to a long-term care facility.
B) Have hospice provided through home care.
C) Discharge the child to home right before death.
D) Have family stay with the child around-the-clock in the hospital.
Ans: B
Feedback:
Many families prefer that a child die at home, surrounded by family and familiar
possessions, rather than in a hospital. For many children, hospice care is furnished as
part of home care, so that they are not separated from their families. This would be the
best suggestion for the nurse to make to the parents of the dying child. A long-term care
facility is similar to a hospital and would not meet the family's needs. Discharging the
child to home prior to death will not meet the needs of the family. Having the family
stay with the child around-the-clock in the hospital definitely will not meet the family's
needs.
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14. During a home visit with a family, the nurse learns that the oldest adolescent son has
been arrested for shoplifting and has been skipping school for months. Which
information within the family's health history could help explain this child's behavior?
A) Father works out of the home.
B) Mother works out of the home.
C) Adolescent did not die as expected as a child.
D) Parents have other children that need time and attention.
Ans: C
Feedback:
Parents who engage in anticipatory grief but the child does not die may have problems
reversing the feelings. The parents begin to treat the child in a cold, unfeeling way. This
child is a vulnerable child or a fragile child and may develop behavioral problems later
such as shoplifting. It is unknown if this child's behavior is linked to the mother and
father working outside of the home or if the behavior is because of the other children's
needs.
15. The nurse caring for children on a pediatric oncology care area delays entering some of
the children's rooms unless to provide medication or perform a procedure. Which stage
of the grieving process is influencing this nurse's ability to provide patient care?
A) Anger
B) Denial
C) Bargaining
D) Depression
Ans: B
Feedback:
There is a danger that a nurse who is in a stage of denial may care for children by
avoiding going into a child's room unless an important procedure must be done. Nurses
who are angry might provide care that is sharp and abrupt. Bargaining is promising to
do something in exchange for the child not dying. Nurses who are in the depression
stage may be ineffective caregivers because problem solving and decision making
becomes a chore.
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