INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
TestINTRODUCTION
Bank - Introduction to Maternity
and Pediatric NursingAND
8e (by PEDIATRIC
Leifer)
Test bank
TO MATERNITY
NURSING 8TH2
EDITION LEIFER TEST BANK
Chapter 01: The Past, Present, and Future
MULTIPLE CHOICE
1. A patient chooses to have the certified nurse midwife (CNM) provide care during her pregnancy. What does
the CNMs scope of practice include?
a. Practice independent from medical supervision
b. Comprehensive prenatal care
c. Attendance at all deliveries
d. Cesarean sections
ANS: B
The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures
that a backup physician is available in case of unforeseen problems.
DIF: Cognitive Level: Comprehension REF: Page 6
TOP: Advance Practice Nursing Roles KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. Which medical pioneer discovered the relationship between the incidence of puerperal fever and unwashed
hands?
a. Karl Cred
b. Ignaz Semmelweis
c. Louis Pasteur
d. Joseph Lister
ANS: B
Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed
hands of physicians and medical students.
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DIF: Cognitive Level: Knowledge REF: Page 2
TOP: The Past KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. A pregnant woman who has recently immigrated to the United States comments to the nurse, I am afraid of
childbirth. It is so dangerous. I am afraid I will die. What is the best nursing response reflecting cultural
sensitivity?
a. Maternal mortality in the United States is extremely low.
b. Anesthesia is available to relieve pain during labor and childbirth.
c. Tell me why you are afraid of childbirth.
d. Your condition will be monitored during labor and delivery.
ANS: C
Asking the patient about her concerns helps promote understanding and individualizes patient care.
DIF: Cognitive Level: Application REF: Page 7
TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation
4. An urban area has been reported to have a high perinatal mortality rate. What information does this provide?
a. Maternal and infant deaths per 100,000 live births per year
b. Deaths of fetuses weighing more than 500 g per 10,000 births per year
c. Deaths of infants up to 1 year of age per 1000 live births per year
d. Fetal and neonatal deaths per 1000 live births per year
ANS: D
The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.
DIF: Cognitive Level: Comprehension REF: Page 12
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
3
OBJ: 9 TOP: The Present-Child Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
5. What is the focus of current maternity practice?
a. Hospital births for the majority of women
b. The traditional family unit
c. Separation of labor rooms from delivery rooms
d. A quality family experience for each patient
ANS: D
Current maternity practice focuses on a high-quality family experience for all families, traditional or otherwise.
DIF: Cognitive Level: Comprehension REF: Page 6
TOP: The Present-Maternity Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
6. Who advocated the establishment of the Childrens Bureau?
a. Lillian Wald
b. Florence Nightingale
c. Florence Kelly
d. Clara Barton
ANS: A
Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau.
DIF: Cognitive Level: Knowledge REF: Page 4
TOP: The Past KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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7. What was the result of research done in the 1930s by the Childrens Bureau?
a. Children with heart problems are now cared for by pediatric cardiologists.
b. The Child Abuse and Prevention Act was passed.
c. Hot lunch programs were established in many schools.
d. Childrens asylums were founded.
ANS: C
School hot lunch programs were developed as a result of research by the Childrens Bureau on the effects of
economic depression on children.
DIF: Cognitive Level: Knowledge REF: Page 4
TOP: The Past KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
8. What government program was implemented to increase the educational exposure of preschool children?
a. WIC
b. Title XIX of Medicaid
c. The Childrens Charter
d. Head Start
ANS: D
Head Start programs were established to increase educational exposure of preschool children.
DIF: Cognitive Level: Knowledge REF: Page 3
TOP: Government Influences in Maternity and Pediatric Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. What guidelines define multidisciplinary patient care in terms of expected outcome and timeframe from
different areas of care provision?
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
4
a. Clinical pathways
b. Nursing outcome criteria
c. Standards of care
d. Nursing care plan
ANS: A
Clinical pathways, also known as critical pathways or care maps, are collaborative guidelines that define
patient care across disciplines. Expected progress within a specified timeline is identified.
DIF: Cognitive Level: Knowledge REF: Page 12
TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
10. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her mother, and collected
admission data. What is the next step the student will take to develop a nursing care plan for this child?
a. Identify measurable outcomes with a timeline.
b. Choose specific nursing interventions for the child.
c. Determine appropriate nursing diagnoses.
d. State nursing actions related to the childs medical diagnosis.
ANS: C
The nurse uses assessment data to select appropriate nursing diagnoses from the NANDA-I list. Outcomes and
interventions are then developed to address the relevant nursing diagnoses.
DIF: Cognitive Level: Application REF: Page 11
TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
11. A nursing student on an obstetric rotation questions the floor nurse about the definition of the LVN/LPN
scope of practice. What resource can the nurseNsUuR
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stGtoTBth.C
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udent?
a. American Nurses Association
b. States board of nursing
c. Joint Commission
d. Association of Womens Health, Obstetric and Neonatal Nurses
ANS: B
The scope of practice of the LVN/LPN is published by the states board of nursing.
DIF: Cognitive Level: Comprehension REF: Page 3
OBJ: 18 TOP: Critical Thinking
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
12. What was recommended by Karl Cred in 1884?
a. All women should be delivered in a hospital setting.
b. Chemical means should be used to combat infection.
c. Podalic version should be done on all fetuses.
d. Silver nitrate should be placed in the eyes of newborns.
ANS: D
In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newborns to reduce the incidence of
blindness.
DIF: Cognitive Level: Knowledge REF: Page 2
TOP: Use of Silver Nitrate KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. What is the purpose of the White House Conference on Children and Youth?
a. Set criteria for normal growth patterns.
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
5
b. Examine the number of live births in minority populations.
c. Raise money to support well-child clinics in rural areas.
d. Promote comprehensive child welfare.
ANS: D
White House Conferences on Children and Youth are held every 10 years to promote comprehensive child
welfare.
DIF: Cognitive Level: Knowledge REF: Page 4
TOP: White House Conferences KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. How many hours of hospital stay does legislation currently allow for a postpartum patient who has
delivered vaginally without complications?
a. 24
b. 48
c. 36
d. 72
ANS: B
Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have
had a cesarean delivery usually stay 4 days.
DIF: Cognitive Level: Knowledge REF: Page 6
TOP: Hospital Terms for Postpartum Patients
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. How does the clinical pathway or critical pathway improve quality of care?
a. Lists diagnosis-specific implementations NURSINGTB.COM
b. Outlines expected progress with stated timelines
c. Prioritizes effective nursing diagnoses
d. Describes common complications
ANS: B
Critical pathways outline expected progress with stated timelines. Any deviation from those timelines is called
a variance.
DIF: Cognitive Level: Comprehension REF: Page 12
TOP: Critical Pathway KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
16. A patient asks the nurse to explain what is meant by gene therapy. What is the nurses best response?
a. Gene therapy can replace missing genes.
b. Gene therapy evaluates the parents genes.
c. Gene therapy can change the sex of the fetus.
d. Gene therapy supports the regeneration of defective genes.
ANS: A
Gene therapy can replace missing or defective genes.
DIF: Cognitive Level: Knowledge REF: Page 8
TOP: Gene Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. The nurse is clarifying information to a patient regarding diagnosis-related groups (DRGs). What is the
nurses best response when the patient asks how DRGs reduce medical care costs?
a. By determining payment based on diagnosis
b. By requiring two medical opinions to confirm a diagnosis
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
6
c. By organizing HMOs
d. By defining a person who will require hospitalization
ANS: A
DRGs determine the amount of payment and length of hospital stay based on the diagnosis.
DIF: Cognitive Level: Comprehension REF: Page 8
TOP: DRGs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
18. What is the best example of a Nursing Interventions Classification (NIC) intervention?
a. Patient will ambulate in the hall independently for 10 minutes three times a day.
b. Nurse will report temperature elevations to the charge nurse.
c. Nurse will offer extra liquids at all meals.
d. Patient will express pain relief after massage.
ANS: C
NIC is a guide to nursing actions.
DIF: Cognitive Level: Comprehension REF: Page 12
OBJ: 15 TOP: NICs KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19. How does electronic charting ensure comprehensive charting more effectively than handwritten charting?
a. Provides a uniform style of chart
b. Requires certain responses before allowing the user to progress
c. All documentation is reflective of the nursing care plan
d. Requires a daily audit by the charge nurse
ANS: B
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Comprehensive electronic documentation is ensured by requiring specific input in designated categories before
the user can progress through the system.
DIF: Cognitive Level: Comprehension REF: Page 15
TOP: Computer Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
20. The nurse reminds family members that the philosophy of family-centered care is to provide control to the
family over health care decisions. What is the appropriate term for this type of control?
a. Empowerment
b. Insight
c. Regulation
d. Organization
ANS: A
The term empowerment refers to the control a family has over its own health care decisions.
DIF: Cognitive Level: Knowledge REF: Page 2
TOP: Empowerment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. A patient in the prenatal clinic is concerned about losing her job because of her pregnancy. The nurse
instructs her that the Family Medical Leave Act (FMLA) allows an employee to be absent from work without
pay. How many weeks does the FMLA allow a woman to recover from childbirth or care for a sick family
member without loss of benefits or pay status?
a. 4
b. 6
c. 10
d. 12
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
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ANS: D
The FMLA allows for employees to leave work for up to 12 weeks to recover from childbirth or to care for an
ill family member without losing benefits or pay status.
DIF: Cognitive Level: Knowledge REF: Page 3
TOP: FMLA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22. What term appropriately describes the nurse who is able to adapt health care practices to meet the needs of
various cultures?
a. Culturally aware
b. Culturally sensitive
c. Culturally competent
d. Culturally adaptive
ANS: C
The nurse who is able to adapt health care to meet the needs of various cultures is said to be culturally
competent.
DIF: Cognitive Level: Knowledge REF: Page 7
TOP: Cultural Competency KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
23. What is one major advantage to the application of critical thinking?
a. Problem-free care
b. Limitation of approaches to care
c. Decreased need for assessment
d. Problem prevention
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ANS: D
Critical thinking results in problem prevention in designing nursing care.
DIF: Cognitive Level: Comprehension REF: Page 14
TOP: Critical Thinking KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
24. Student practical nurses are discussing the North American Nursing Diagnosis Association International
(NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role
of the LPN with nursing diagnosis formulation is what?
a. To initiate and identify nursing diagnosis specific to patient
b. To update changes in nursing diagnosis as needed
c. To have an understanding of nursing diagnosis terminology
d. To accurately document nursing diagnosis on patient plan of care
ANS: C
The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses. The licensed
practical nurse is responsible to have an understanding of nursing diagnosis terminology.
DIF: Cognitive Level: Comprehension REF: Page 14
TOP: NANDA-I taxonomy KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques
MULTIPLE RESPONSE
25. What services are birthing centers able to provide? (Select all that apply.)
a. Prenatal care
b. Labor and delivery services
c. Classes for new mothers
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
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d. Adoption referrals
e. Family planning
ANS: A, B, C, E
Birthing centers are capable of providing full-service obstetric care, classes for new mothers, and family
planning. Birthing centers do not offer adoption services.
DIF: Cognitive Level: Comprehension REF: Page 6
TOP: Birthing Centers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
26. What developments in the early 20th century encouraged women to seek hospitalization for childbirth?
(Select all that apply.)
a. Use of specialized obstetric instruments
b. Use of anesthesia
c. Physicians closer relationships with hospitals
d. Focus on family-centered care
e. Insurance coverage
ANS: A, B, C
In the early 1900s, the development of specialized obstetric instruments, better modes of anesthesia, and the
physicians reliance on hospital services were instrumental in encouraging women to seek hospitalization for
childbirth.
DIF: Cognitive Level: Comprehension REF: Page 3
TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
27. What nonfamily-centered policies were prevalent in the 1960s? (Select all that apply.)
a. Waiting room for fathers
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b. Sedation of mother during labor
c. Delay of reunion of mother and infant
d. Lenient visiting hours
e. Restrictions of visitations by minor children
ANS: A, B, C, E
Hospital policies in the 1960s provided a separate waiting room for fathers while the mother went through
labor in a sedated state. The reunion of mother and infant was delayed for several hours because of the
sedation. Visiting hours were rigid and disallowed the visitation of minor children.
DIF: Cognitive Level: Comprehension REF: Page 3
TOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28. The nurse is aware that there is a legal responsibility to report certain diseases and conditions to county or
state health authorities. Which would be included? (Select all that apply.)
a. Tuberculosis
b. Child abuse
c. Industrial accidents
d. Sexually transmitted diseases
e. Food-borne infections
ANS: A, B, D, E
The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually
transmitted diseases), food-borne infections, child abuse, and threats of suicide.
DIF: Cognitive Level: Comprehension REF: Page 6
OBJ: 6 TOP: Reportable Diseases
KEY: Nursing Process Step: Planning
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
9
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
29. An inservice program at a long-term care facility is reviewing the Nursing Outcomes Classification (NOC)
with nursing staff. After the presentation the nurses review resident care plans. Which of the following are
found to be appropriately written outcomes? (Select all that apply.)
a. Suction patient orally every 4 hours and as needed.
b. Auscultate lung sounds every 2 hours.
c. Provide Tylenol as ordered by health care provider.
d. Patient states Pain has decreased after medication administration.
e. Patient blood pressure recorded as 120/72 after dressing change.
ANS: D, E
NOC was developed to identify outcomes of nursing care that are directly influenced by nursing actions.
Outcomes are defined as the behaviors and feelings of the patient in response to the nursing care given.
Suctioning patient, auscultating lung sounds, and providing Tylenol are nursing actions.
DIF: Cognitive Level: Application REF: Page 12
TOP: Nursing Outcomes Classification (NOC)
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30. Practical nursing students are using critical thinking skills to study for an upcoming test. What will these
students include when studying? (Select all that apply.)
a. Memorization of facts first
b. Prioritizing information
c. Relating facts to other facts
d. Making assumptions
e. Reviewing before the test
ANS: B, C, E
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Using critical thinking when studying involves understanding facts before memorizing, prioritizing
information to be memorized, relating facts to other facts, using all five senses, reviewing before tests, and
reading critically. Critical thinking does not involve assumption as does general thinking.
DIF: Cognitive Level: Comprehension REF: Page 15
TOP: Critical Thinking KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment
31. What factors have played a role in meeting the goals of Healthy People 2020 as it relates the goals for
outcomes of pregnancy? (Select all that apply.)
a. Early prenatal care
b. Increased number of surgical births
c. NICU care
d. Use of prenatal glucocorticoids
e. Fetal surgery
ANS: A, C, D, E
Early prenatal care, fetal surgery, use of prenatal glucocorticoids, technology, and NICU care have played a
role in increasing the positive outcome of pregnancy, and the goals of Healthy People 2020 may well be met.
Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People
2020.
DIF: Cognitive Level: Comprehension REF: Page 16
TOP: Healthy People 2020 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
32. A community health nurse is providing specialized care to patients in the home setting. What kind of
specialized care may this nurse be providing? (Select all that apply.)
a. Glucose monitoring
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
10
b. Heparin therapy
c. Family education
d. Total parenteral nutrition
e. Provision of referral services
ANS: A, B, D
Glucose monitoring, heparin therapy, and total parenteral nutrition are categorized as specialized care that may
be provided by the community health nurse. Family education and provision of referral are categorized as
therapeutic care.
DIF: Cognitive Level: Application REF: Page 16
TOP: Community Health KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
33. The nurse who is very conscientious about hand hygiene is following the concepts set out by
and
.
ANS:
Lister, Pasteur OR Pasteur, Lister
Both Lister and Pasteur set out that handwashing could reduce incidence of infection by cross-contamination.
DIF: Cognitive Level: Knowledge REF: Page 2
TOP: Handwashing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
34. The first White House Conference on Children and Youth was called by President
.
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ANS:
Theodore Roosevelt
Theodore Roosevelt called the first White House Conference in 1909.
DIF: Cognitive Level: Knowledge REF: Page 4
TOP: White House Conferences KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
35. The nurse reviewing the specific recovery goals set out on a clinical pathway observed that two goals were
not met by their designated timeline. The nurse records a negative
for these two goals.
ANS:
variance
Using a clinical pathway model with goals and associated timelines, the nurse must record a negative variance
when a timeline is not met and consider a new approach or an extended timeline.
DIF: Cognitive Level: Comprehension REF: Page 12
TOP: Variances KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
36.
.
is purposeful, goal-directed thinking based on scientific
evidence rather than assumption or memorization.
ANS:
Critical thinking
Critical thinking is purposeful and goal-directed thinking as opposed to general thinking, which involves
NURSINGTB.COM
INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
random or memorized thoughts.
DIF: Cognitive Level: Knowledge REF: Page 14
TOP: Critical Thinking KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
12
Chapter 02: Human Reproductive Anatomy and Physiology
MULTIPLE CHOICE
1. A 14-year-old boy is at the pediatric clinic for a checkup. What physical changes of puberty will the nurse
indicate are related to the production of testosterone?
a. Stimulation of production of white cells and platelets
b. Promotion of growth of small bones
c. Increase in muscle mass and strength
d. Decrease in production of sebaceous gland secretions
ANS: C
Testosterone increases muscle mass, promotes strength and growth of long bones, and enhances production of
red blood cells.
DIF: Cognitive Level: Knowledge REF: Page 22
TOP: Male Reproductive System KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. The nurse is educating high school students about puberty. What will the nurse indicate regulates the
production of sperm and secretion hormones?
a. Testes
b. Vas deferens
c. Ejaculatory ducts
d. Prostate gland
ANS: A
The testes have two functions: manufacture of spermatozoa and secretion of androgens.
DIF: Cognitive Level: Knowledge REF: PageN2U
3 RSINGTB.COM
TOP: Male Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the couple is a
factor that can decrease sperm production?
a. Infrequent sexual intercourse
b. The man not being circumcised
c. The penis and testes being small
d. The testes being too warm
ANS: D
The scrotum is suspended away from the perineum to lower the temperature of the testes for sperm production.
DIF: Cognitive Level: Comprehension REF: Page 24
TOP: Male Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. When describing the female reproductive tract to a pregnant woman, the nurse would explain that which
uterine layer is involved in implantation?
a. Perimetrium
b. Endometrium
c. Myometrium
d. Internal os
ANS: B
The endometrium is the inner mucosal layer of the uterus that is governed by cyclical hormonal changes. It is
functional during menstruation and during the implantation of a fertilized ovum.
DIF: Cognitive Level: Knowledge REF: Page 23
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
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TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A group of nursing students plans to teach a class of sixth-grade girls about menstruation. What correct
information will the nursing students teach to the class?
a. Menarche usually occurs around 12 years of age.
b. Ovulation occurs regularly from the very first cycle.
c. A regular cycle is established by the third period.
d. Typically, menstrual flow is heavy and lasts up to 10 days.
ANS: A
The beginning of menstruation, called menarche, occurs at about 12 years of age. Early cycles are irregular and
anovulatory.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Female Reproductive Cycle and Menstruation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. A 10-year-old girl asks the nurse, What is the first sign of puberty? What is the correct nursing response?
a. An increase in height
b. Breast development
c. Appearance of axillary hair
d. The first menstrual period
ANS: B
The first outward change of puberty in girls is the development of breasts at about 10 to 11 years of age.
DIF: Cognitive Level: Knowledge REF: Page 23
TOP: PubertyFemale KEY: Nursing Process SNteUpR: SIm
nO
taM
tion
INpGleTm
Be.C
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. A 12-year-old female pediatric patient experienced menarche 3 months ago. Her mother voices concern to
the pediatric office nurse regarding the irregularity of her daughters menstrual cycle. What is the nurses best
response?
a. Worrying is not the answer.
b. I will talk to the pediatrician about a gynecological referral.
c. I can only discuss this with your daughter.
d. Early cycles are often irregular.
ANS: D
Early cycles are often irregular and may be anovulatory. Regular cycles are usually established within 6
months to 2 years of the menarche. In an average cycle, the flow (menses) occurs every 28 days, plus or minus
5 to 10 days.
DIF: Cognitive Level: Application REF: Page 29
TOP: Menstrual Cycle KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. Which hormone initiates the maturation of the ovarian follicle?
a. Estrogen
b. Follicle-stimulating hormone
c. Progesterone
d. Luteinizing hormone
ANS: B
Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.
DIF: Cognitive Level: Knowledge REF: Page 29
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
14
TOP: Female Reproductive Cycle KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. What statement indicates a woman has correct information about oogenesis?
a. Women make fewer ova as they age.
b. Women have all of their ova at the time they are born.
c. Ova production begins at birth and continues until puberty.
d. New ova are made every month from puberty to climacteric.
ANS: B
Oogenesis (formation of immature ova) does not occur after fetal development. Females are born with about 2
million immature ova, which rapidly reduce by adulthood.
DIF: Cognitive Level: Comprehension REF: Page 27
TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. A pregnant woman asks the nurse, Will I be able to have a vaginal delivery? The nurse knows that which is
the most favorable pelvic type for vaginal birth?
a. Gynecoid
b. Android
c. Anthropoid
d. Platypelloid
ANS: A
The gynecoid pelvis is the typical female pelvis and is most favorable for vaginal birth.
DIF: Cognitive Level: Knowledge REF: Page 27
TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INPG
reTvBen.CtiO
oM
n and Early Detection of Disease
11. A mother is anxious about her ability to breastfeed after her child is born because of her small breast size.
What would be an important point to teach this mother?
a. Milk is produced in ducts and lobules regardless of breast size.
b. Supplementing breastfeeding with formula allows the infant to receive adequate nutrition.
c. Breast size can be increased with exercise.
d. Drinking extra milk during pregnancy allows breasts to produce adequate amounts of milk.
ANS: A
Breast size does not influence the ability to secrete milk.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
12. For what is the decrease in estrogen and progesterone during the menstrual cycle responsible?
a. Degeneration of the corpus luteum
b. Ovulation
c. Follicle maturation
d. Shedding of the endometrium
ANS: D
The fall in estrogen and progesterone causes the endometrium to break down, resulting in menstruation.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Female Reproductive Cycle KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. The nurse is assisting with pelvic inlet measurements on a pregnant woman. What measurement will
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provide the nurse with information about whether the woman can deliver vaginally?
a. Diagonal conjugate
b. Obstetric conjugate
c. Transverse diameter
d. Anteroposterior diameter
ANS: B
This measurement determines if the fetus can pass through the birth canal.
DIF: Cognitive Level: Comprehension REF: Page 28
TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. The nurse has explained menstruation to a 13-year-old girl. What statement indicates the girl needs
additional education?
a. Periods last about 5 days.
b. My cycle should get regular in 6 months.
c. I should expect heavy bleeding with clots.
d. Periods come about every 4 weeks.
ANS: C
Clots are not normally seen in menstrual discharge. A normal menstrual flow is 30 to 40 mL blood and 30 to
50 mL serous fluid.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. A mother asks the nurse, When will I know my child has entered puberty? What will the nurse state based
on an understanding of changes associated witNhUpRuSbIeN
rtG
y?TB.COM
a. Your daughter will have her first period.
b. Youll recognize puberty by the mood swings.
c. The child becomes interested in the opposite sex.
d. Secondary sex characteristics, such as pubic hair, appear.
ANS: D
Puberty begins when the secondary sex characteristics appear. Puberty ends when mature sperm are formed in
the male and when regular menstrual cycles occur in the female.
DIF: Cognitive Level: Comprehension REF: Page 22
TOP: Puberty KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. A nurse is planning to teach couples about the physiology of the sex act. What correct information will the
nurse provide?
a. Fertilization of an ovum requires penetration by several sperm.
b. An ovum must be fertilized within 24 hours of ovulation.
c. It takes 4 to 5 days for sperm to reach the fallopian tubes.
d. Sperm live for only 24 hours following ejaculation.
ANS: B
After ovulation, the egg lives for only 24 hours. Sperm must be available during that time if fertilization is to
occur.
DIF: Cognitive Level: Comprehension REF: Page 31
TOP: Physiology of the Sex Act KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. A newly married couple tells the nurse they would like to wait a few years before starting a family. Which
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statement made by the man indicates an understanding about sexual activity and pregnancy?
a. My wife cant get pregnant if I withdraw before climax.
b. A man can secrete semen before ejaculation.
c. If we dont have intercourse very often, my wife wont get pregnant.
d. It is safe to ejaculate outside the vagina.
ANS: B
Semen may be secreted during sexual intercourse before ejaculation.
DIF: Cognitive Level: Comprehension REF: Page 31
TOP: Male Reproductive System KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters
of the obstetric conjugate?
a. 10 to 10.5
b. 11 to 11.5
c. 12.5 to 13
d. 14 to 14.5
ANS: A
The obstetric conjugate is approximately 1.5 to 2 centimeters shorter than the diagonal conjugate.
DIF: Cognitive Level: Knowledge REF: Page 28
TOP: Obstetric Conjugate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about the female
anatomy. What is true about fimbriae?
a. They form the passageway for the sperm toNmUeRetStIhNeGoTvBu.m
.M
CO
b. They are the site of fertilization.
c. They are fingerlike projections that capture the ovum.
d. They propel the egg through the fallopian tube.
ANS: C
Fimbriae are the fingerlike projections from the infundibulum that capture the ovum at ovulation and conduct i
into the fallopian tube.
DIF: Cognitive Level: Comprehension REF: Page 27
TOP: Fimbriae KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. What will the nurse explain to a 12-year-old patient when describing what characterizes nocturnal
emissions?
a. A drop in testosterone level
b. Sexual stimulation
c. Absence of sperm in ejaculate
d. Association with violent dreams
ANS: C
Nocturnal emissions, also known as wet dreams, occur without sexual stimulation and contain no sperm.
Testosterone levels are constant until midlife.
DIF: Cognitive Level: Comprehension REF: Page 23
TOP: Nocturnal Emissions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. The nurse is educating a pregnant patient who expects to breastfeed. The nurse knows that when a patient
breastfeeds, which portions of the breast secrete milk?
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a. Lactiferous sinuses
b. Lobes
c. Montgomerys glands
d. Alveoli
ANS: D
The alveoli secrete milk.
DIF: Cognitive Level: Knowledge REF: Page 29
TOP: Milk Secretion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. Where are the secretions responsible for nourishing sperm excreted from?
a. Vas deferens
b. Epididymis
c. Cowpers gland
d. Scrotum
ANS: C
The Cowpers gland secretions nourish the sperm.
DIF: Cognitive Level: Knowledge REF: Page 24
TOP: Cowpers Gland KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23. What signifies the end of puberty for a male?
a. Facial hair is evident.
b. Erections can be sustained.
c. Ejaculate is greater than 5 mL.
d. Mature sperm are formed.
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ANS: D
Puberty ends for a male when mature sperm are formed by the testes.
DIF: Cognitive Level: Knowledge REF: Page 22
TOP: End of Puberty KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24. How long does sperm remain viable in the female reproductive tract?
a. 12 hours
b. 1 day
c. 2 days
d. 4 days
ANS: D
Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days.
DIF: Cognitive Level: Knowledge REF: Page 31
TOP: Viability of Sperm KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. The nurse encourages the members of a prenatal class to seriously consider breastfeeding. What does
breast milk provide in addition to nourishment for the infant?
a. Maternal antibodies
b. Stimulus for red blood cell production
c. Endorphins that soothe the infant
d. Hormones that stimulate growth
ANS: A
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Breast milk provides maternal antibodies to the infant that give the child acquired immunity from some
diseases for several months.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Properties of Breast Milk KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26. A female patient reports her menstrual cycle consistently occurs every 32 days. What day of her cycle can
the woman anticipate ovulation?
a. 14
b. 16
c. 18
d. 20
ANS: C
Ovulation occurs when a mature ovum is released from the follicle about 14 days before the onset of the next
menstrual period.
DIF: Cognitive Level: Analysis REF: Page 29
TOP: Menstrual Cycle KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
27. The nurse conducting a sex education class for junior high students describes some cultural rites
celebrating the entry to adulthood. What information would the nurse include? (Select all that apply.)
a. Bar mitzvah
b. Displays of bravery
c. Receiving part of their inheritance
d. Ritual circumcision
NURSINGTB.COM
e. Displays of self-defense
ANS: A, B, D, E
Some cultures celebrate the entry to adulthood with rites such as displays of strength, bravery, self-reliance,
and self-defense. Ritual circumcisions and bar and bat mitzvahs are also entry rites to adulthood. Lack of such
rituals can sometimes confuse young people because there is no evidence of acceptance as an adult.
DIF: Cognitive Level: Knowledge REF: Page 22
TOP: Rites of Passage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. The nurse is reading a pregnant patients history and physical. What information does the nurse recognize
might indicate the need for a cesarean delivery? (Select all that apply.)
a. History of childhood rickets
b. Immobile coccyx
c. Prepregnant weight of 100 pounds
d. Avid horse rider
e. Pelvic fracture 3 years ago
ANS: A, B, E
Pelvic conditions that may predispose to a cesarean delivery are childhood rickets, pelvic fracture, and
immobile coccyx.
DIF: Cognitive Level: Comprehension REF: Page 29
TOP: Pelvic Conditions Predisposing Cesarean Delivery
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
29. What are considered to be functions of the fallopian tubes? (Select all that apply.)
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a. Passage for sperm to meet ova
b. Passage for ovum to uterus
c. Safe environment for zygote
d. Restriction for only one ovum to enter uterus
e. Site for fertilization
ANS: A, B, C, E
The fallopian tube provides passage for both sperm and ova, offering an optimum place for fertilization and a
safe environment for the zygote.
DIF: Cognitive Level: Knowledge REF: Page 27
TOP: Function of Fallopian Tubes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30. The nurse is providing an inservice to students beginning their obstetric clinical rotation. Using a diagram,
the nurse points out parts of the female pelvis. What will the nurse include? (Select all that apply.)
a. Two innominates
b. Obstetric conjugate
c. Sacrum
d. Perimetrium
e. Coccyx
ANS: A, C, E
The bones of the pelvis are two innominates, the sacrum, and the coccyx.
DIF: Cognitive Level: Knowledge REF: Page 27
TOP: Bones of the Pelvis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The nurse explains that testosterone is respNoUnR
siSbIlN
eG
foTrBm.CaO
leM
s exceeding females in which aspects? (Select
all that apply.)
a. Strength
b. Height
c. Mental concentration
d. Hematocrit levels
e. Agility
ANS: A, B, D DIF: Cognitive Level: Knowledge REF: Page 23
OBJ: 2 TOP: Effects of Testosterone
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32. A patient is being seen by her health care provider for a suspected vaginal infection. What will the nurse
include when educating this patient on factors that affect the vaginal pH? (Select all that apply.)
a. Antibiotic therapy
b. Frequent douching
c. Exercise
d. Jet lag
e. Use of vaginal sprays
ANS: A, B, E
The vagina is self-cleansing and during the reproductive years maintains a normal acidic pH of 4 to 5. The self
cleansing activity may be altered by antibiotic therapy, frequent douching, and excessive use of vaginal sprays,
deodorant sanitary pads, or deodorant tampons.
DIF: Cognitive Level: Application REF: Page 25
TOP: Female Reproductive Organs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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COMPLETION
33. When the nurse reads in the history and physical of a pregnant patient that she has a platypelloid pelvis, the
nurse is aware that this pelvis has a narrow
diameter, making a vaginal birth unlikely.
ANS:
anteroposterior
The platypelloid pelvis is very narrow from front to back (anteroposterior). The shape of this pelvis makes
vaginal delivery unlikely.
DIF: Cognitive Level: Comprehension REF: Page 27
OBJ: 8 TOP: Platypelloid Pelvis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
34. In males the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH) from the anterior
pituitary stimulate testosterone production in the
cells of the testes.
ANS:
Leydig
The Leydig cells in the testes are stimulated by the FSH and LH to produce testosterone.
DIF: Cognitive Level: Knowledge REF: Page 24
TOP: Leydig Cells KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
35. The
is a period of years during which the womans ability to reproduce gradually declines.
ANS:
climacteric
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The climacteric is a period of years during which the womans ability to reproduce gradually declines.
DIF: Cognitive Level: Knowledge REF: Page 29
TOP: Female Reproduction KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36. Where the labia majora and the labia minora meet is known as the fourchette or
.
ANS:
obstetrical perineum
Where the labia majora and the labia minora meet is known as the fourchette or obstetrical perineum.
Lacerations in this area often occur during childbirth.
DIF: Cognitive Level: Knowledge REF: Page 24
TOP: Female Anatomy KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
37. The nurse outlines the phases of the sexual response. Arrange the phases in order of occurrence. Put a
comma and space between each answer choice (a, b, c, d, etc.)
a. Nipples become erect.
b. Involuntary muscle spasms occur.
c. Engorgement resolves.
d. Heart rate slows.
e. Skin flushes.
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ANS: A, E, B, C, D
DIF: Cognitive Level: Comprehension REF: Page 31
TOP: Sexual Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 03: Fetal Development
MULTIPLE CHOICE
1. What is the total number of chromosomes contained in a mature sperm or ovum?
a. 22
b. 23
c. 44
d. 46
ANS: B
Gametes (sex chromosomes) contain 23 chromosomes.
DIF: Cognitive Level: Knowledge REF: Page 33
TOP: Gametogenesis KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. A pregnant woman states, My husband hopes I will give him a boy because we have three girls. What will
the nurse explain to this woman?
a. The sex chromosome of the fertilized ovum determines the gender of the child.
b. When the sperm and ovum are united, there is a 75% chance the child will be a girl.
c. When the pH of the female reproductive tract is acidic, the child will be a girl.
d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.
ANS: D
When a Y-bearing sperm fertilizes an ovum, a male child is produced.
DIF: Cognitive Level: Comprehension REF: Page 35
TOP: Sex Determination KEY: Nursing Process Step: Implementation
Bt.C
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
3. What is the most common site for fertilization?
a. Lower segment of the uterus
b. Outer third of the fallopian tube near the ovary
c. Upper portion of the uterus
d. Area of the fallopian tube farthest from the ovary
ANS: B
Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.
DIF: Cognitive Level: Knowledge REF: Page 35
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The embryo is termed a fetus at which stage of prenatal development?
a. 2 weeks
b. 4 weeks
c. 9 weeks
d. 16 weeks
ANS: C
The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of
gestation or until birth.
DIF: Cognitive Level: Knowledge REF: Page 38
TOP: Prenatal Developmental Milestones
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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5. The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the
placenta to the fetus. What vessel(s) carry blood to the fetus?
a. One umbilical vein
b. Two umbilical veins
c. One umbilical artery
d. Two umbilical arteries
ANS: A
The umbilical vein transports richly oxygenated blood from the placenta to the fetus.
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Fetal Circulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. Where is the usual location for implantation of the zygote?
a. Upper section of the posterior uterine wall
b. Lower portion of the uterus near the cervical os
c. Inner third of the fallopian tube near the uterus
d. Lateral aspect of the uterine wall
ANS: A
The zygote usually implants in the upper section of the posterior uterine wall.
DIF: Cognitive Level: Knowledge REF: Page 37
TOP: Implantation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the
uterine wall?
a. Amnion
NURSINGTB.COM
b. Yolk sac
c. Chorion
d. Decidua basalis
ANS: C
The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.
DIF: Cognitive Level: Knowledge REF: Page 37
TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. Which hormone is responsible for converting the endometrium into decidual cells for implantation?
a. Estrogen
b. Human chorionic gonadotropin
c. Human placental lactogen
d. Progesterone
ANS: D
At high levels, progesterone maintains the endometrial lining for implantation of the zygote.
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Placenta KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. A patient asks the nurse when her infants heart will begin to pump blood. What will the nurse reply?
a. By the end of week 3
b. Beginning in week 8
c. At the end of week 16
d. Beginning in week 24
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ANS: A
The fetal heart begins to pump by week 3 of gestation.
DIF: Cognitive Level: Knowledge REF: Page 38
TOP: Prenatal Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. What organ does the ductus venosus shunt blood away from in fetal circulation?
a. Liver
b. Heart
c. Lungs
d. Kidneys
ANS: A
Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Prenatal Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. What complication can result from untreated respiratory distress in the newborn?
a. Esophageal atresia
b. Gastric dilation
c. Cold stress
d. Reopening of the foramen ovale
ANS: D
Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale
NURSINGTB.COM
DIF: Cognitive Level: Comprehension REF: Page 42
TOP: Fetal Circulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12. During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of
this pregnancy?
a. Dizygotic twins
b. Monozygotic twins
c. Conjoined twins
d. High birth-weight twins
ANS: A
Dizygotic twins always have two amnions and two chorions (placentas).
DIF: Cognitive Level: Comprehension REF: Page 44
TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain
is one physical characteristic present in a 25-week-old fetus?
a. Lanugo covering the body
b. Constant motion
c. Skin that is pink and smooth
d. Eyes that are closed
ANS: A
By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus
has definite periods of movement and sleeping.
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DIF: Cognitive Level: Comprehension REF: Page 39
OBJ: 5 TOP: Prenatal Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. At what point in prenatal development do the lungs begin to produce surfactant?
a. 17 weeks
b. 20 weeks
c. 25 weeks
d. 30 weeks
ANS: C
During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate
lung oxygenation to occur.
DIF: Cognitive Level: Knowledge REF: Page 39
OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test.
Which placental hormone is measured in pregnancy tests?
a. Progesterone
b. Estrogen
c. Human chorionic gonadotropin
d. Human placental lactogen
ANS: C
Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon
as implantation occurs, usually 7 to 9 days after fertilization.
NURSINGTB.COM
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. When preparing to teach a class about prenatal development, the nurse would include information about
folic acid supplementation. What is folic acid known to prevent?
a. Congenital heart defects
b. Neural tube defects
c. Mental retardation
d. Premature birth
ANS: B
It is now known that folic acid supplements can prevent neural tube defects such as spina bifida.
DIF: Cognitive Level: Comprehension REF: Page 39
TOP: Prenatal Development KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of
viability?
a. 14 weeks
b. 20 weeks
c. 25 weeks
d. 30 weeks
ANS: B
By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of
viability).
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DIF: Cognitive Level: Knowledge REF: Page 39
TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of
children carrying the dominant gene if one parent has a dominant gene and the other parent does not?
a. 10%
b. 25%
c. 50%
d. 100%
ANS: C
If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.
DIF: Cognitive Level: Comprehension REF: Page 36
TOP: Dominant Traits KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the
most likely cause?
a. Inadequate space in the uterus
b. Inadequate blood supply
c. Inadequate maternal health
d. Inadequate placental nutrition
ANS: D
The single placenta may not be able to provide adequate nutrition to two fetuses.
DIF: Cognitive Level: Comprehension REF: Page 44
TOP: Low Birth-weight Twins KEY: NursingNPUroRcSeIsNsGSTteBp.:CIO
mM
plementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm
ejaculated near the cervix?
a. They are destroyed by the acidic pH of the vagina.
b. They survive up to 5 days and can cause pregnancy.
c. They lose their motility in about 12 hours after intercourse.
d. They are usually pushed out of the vagina by the muscular action of the vaginal wall.
ANS: B
Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.
DIF: Cognitive Level: Comprehension REF: Page 35
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse?
a. Age
b. Estrogen level
c. Body temperature
d. Level of feminine hygiene
ANS: B
Estrogen levels and the pH of the female reproductive tract can affect the survival of the X- and Y-bearing
sperm as well as their motility.
DIF: Cognitive Level: Knowledge REF: Page 35
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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22. Of what is the normal umbilical cord comprised?
a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus
b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus
c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus
d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus
ANS: C
The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to
the fetus.
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Fetal Circulation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23. What part of the fetal body derives from the mesoderm?
a. Nails
b. Oil glands
c. Muscles
d. Lining of the bladder
ANS: C
The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm.
The lining of the bladder derives from the endoderm.
DIF: Cognitive Level: Knowledge REF: Page 37
OBJ: 4 TOP: Embryonic development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24. A couple just learned they are expecting their first child and are curious if they are having a boy or a girl.
At what point of development can the couple fNirUstReSxIN
peGcT
tB
to.CseOeMthe sex of their child on ultrasound?
a. 4 weeks gestational age
b. 6 weeks gestational age
c. 10 weeks gestational age
d. 16 weeks gestational age
ANS: C
The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound
examination.
DIF: Cognitive Level: Knowledge REF: Page 39
TOP: Fetal Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
25. A nurse is teaching a lesson on fetal development to a class of high school students and explains the
primary germ layers. What are the germ layers? (Select all that apply.)
a. Ectoderm
b. Endoderm
c. Mesoderm
d. Plastoderm
e. Blastoderm
ANS: A, B, C
The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm.
DIF: Cognitive Level: Knowledge REF: Page 37
OBJ: 4 TOP: Primary Germ Layers
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. What are the functions of amniotic fluid? (Select all that apply.)
a. Maintaining an even temperature
b. Impeding excessive fetal movement
c. Lubricating fetal skin
d. Acting as a reservoir for nutrients
e. Acting as a cushion for the fetus
ANS: A, E
The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin;
allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus. Although the
fetus does swallow amniotic fluid, it has no nutritional value.
DIF: Cognitive Level: Knowledge REF: Page 37
OBJ: 6 TOP: Amniotic Fluid
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the
nurse include when educating this patient? (Select all that apply.)
a. Dizygotic twins are the same sex.
b. Dizygotic twins share a placenta.
c. Dizygotic pregnancies tend to repeat in families.
d. Dizygotic twins have separate chorions.
e. Dizygotic twin incidence decreases with maternal age.
ANS: C, D
Dizygotic twins tend to repeat in families and have separate chorions. They can be the same sex or different
sexes and have their own placenta. Incidence iNnU
crReS
asIN
esGw
TiBth.Cm
OaM
ternal age.
DIF: Cognitive Level: Comprehension REF: Page 44
TOP: Dizygotic Twins KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
28. The nurse explains that prior to fertilization each cell is reduced from 46 chromosomes to 23 chromosomes
This is referred to as the
number.
ANS:
haploid
When each cell reduces its chromosomes from 46 to 23, it is called the haploid number.
DIF: Cognitive Level: Knowledge REF: Page 34
TOP: Haploid Number KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29. The component of development that programs the genetic code into the nucleus of the cell is
.
ANS:
DNA
The DNA programs the genetic code to the nucleus of the cell to be replicated.
DIF: Cognitive Level: Knowledge REF: Page 33
OBJ: 4 TOP: DNA KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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29
30. The vessels comprising the umbilical cord are cushioned and protected by a substance called
.
ANS:
Whartons jelly
Whartons jelly is a substance in the umbilical cord that cushions and protects the vessels.
DIF: Cognitive Level: Knowledge REF: Page 41
TOP: Fetal Circulation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The normal volume of amniotic fluid is approximately
mL at 37 weeks gestation.
ANS:
1000
The volume of amniotic fluid steadily increases from about 30 mL at 10 weeks of pregnancy to 350 mL at 20
weeks. The volume of fluid is about 1000 mL at 37 weeks. In the latter part of pregnancy the fetus may
swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid.
DIF: Cognitive Level: Knowledge REF: Page 37
TOP: Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32. Organize the developmental stages in the correct order. Put a comma and space between each answer
choice (a, b, c, d, etc.)
a. Fetus
b. Zygote
c. Embryo
d. Blastocyst
e. Morula
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ANS:
B, E, D, C, A
The development follows these stages: zygote, morula, blastocyst, embryo, and fetus.
DIF: Cognitive Level: Comprehension REF: Page 36
TOP: Fetal Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. Put the embryonic/fetal characteristics in the correct order of occurrence from week 3 to week 36 of
gestation. Put a comma and space between each answer choice (a, b, c, d, etc.)
a. Subcutaneous fat is present.
b. Bone marrow forms blood cells.
c. Spinal cord and brain appear.
d. Skull and jaw ossify.
e. Neural tube closes.
ANS:
C, E, D, B, A
Primitive spinal cord and brain appear at 3 weeks. Neural tube closes at 4 weeks. Skull and jaw ossify at 6
weeks. Spleen stops forming blood cells and bone marrow takes over at 29 weeks. Subcutaneous fat is present
at 36 weeks.
DIF: Cognitive Level: Comprehension REF: Page 37
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OBJ: 5 TOP: Fetal Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
NURSINGTB.COM
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
Test Bank - Introduction to Maternity and Pediatric Nursing 8e (by Leifer)
31
Chapter 04: Prenatal Care and Adaptations to Pregnancy
MULTIPLE CHOICE
1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old
son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history
using the TPALM system?
a. Gravida 2, para 20120
b. Gravida 3, para 10011
c. Gravida 3, para 10110
d. Gravida 2, para 11110
ANS: C
Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para.
DIF: Cognitive Level: Application REF: Page 51
OBJ: 1 TOP: Definition of Terms
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How
frequently will the nurse assist the patient to schedule these appointments?
a. Every 3 weeks until the 6th month, then every 2 weeks until delivery
b. Every 4 weeks until the 7th month, after which appointments will become more frequent
c. Monthly until the 8th month
d. Every 2 to 3 weeks for the entire pregnancy
ANS: B
Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks.
From 36 weeks until delivery, visits are weeklNyU
. RSINGTB.COM
DIF: Cognitive Level: Application REF: Page 49
TOP: Prenatal Visits KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What
is Chadwicks sign?
a. Bluish or purplish discoloration of the vulva, vagina, and cervix
b. Presence of early fetal movements
c. Darkening of the areola and breast tenderness
d. Palpation of the fetal outline
ANS: A
Chadwicks sign is the purplish or bluish discoloration of the cervix and vagina.
DIF: Cognitive Level: Knowledge REF: Page 52
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during
pregnancy. What would the nurse explain as the cause of Chadwicks sign?
a. Enlargement of the uterus
b. Progesterone action on the breasts
c. Increasing activity of the fetus
d. Vascular congestion in the pelvic area
ANS: D
Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area.
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DIF: Cognitive Level: Comprehension REF: Page 52
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that
the woman understands the information?
a. Blood pressure goes up toward the end of pregnancy.
b. My breathing will get deeper and a little faster.
c. Ill notice a decreased pigmentation in my skin.
d. There will be a curvature in the upper spine area.
ANS: B
The pregnant woman breathes more deeply, and her respiratory rate may increase slightly.
DIF: Cognitive Level: Comprehension REF: Page 55
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans
expected delivery date using Ngeles rule?
a. April 30, 2014
b. May 5, 2014
c. May 12, 2014
d. May 26, 2014
ANS: C
To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual
period, then add 7 days and change the year ifNnU
ecReSsIsN
arGyT. B.COM
DIF: Cognitive Level: Analysis REF: Page 51
OBJ: 5 TOP: Determining Estimated Date of Delivery
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler
device. How early might fetal heart tones be detected with an electronic Doppler device?
a. 4 weeks
b. 8 weeks
c. 10 weeks
d. 14 weeks
ANS: C
The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device.
DIF: Cognitive Level: Knowledge REF: Page 53
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart
rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the
nurses first action?
a. Ask if the patient has taken a sedative.
b. Notify the physician.
c. Turn the patient to her right side.
d. Record the rate as a normal finding.
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ANS: D
The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be
recorded as normal. The FHR drops in the late stages of pregnancy.
DIF: Cognitive Level: Application REF: Page 53
TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. A womans prepregnant weight is determined to be average for her height. What will the nurse advise the
woman regarding recommended weight gain during pregnancy?
a. 10 to 20 pounds
b. 15 to 25 pounds
c. 25 to 35 pounds
d. 28 to 40 pounds
ANS: C
The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds.
DIF: Cognitive Level: Knowledge REF: Page 60
TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the
woman responds, I dont like milk. What dietary adjustments could the nurse recommend?
a. Increase intake of organ meats.
b. Eat more green leafy vegetables.
c. Choose more fresh fruits, particularly citrus fruits.
d. Include molasses and whole-grain breads in the diet.
ANS: B
NURSINGTB.COM
For women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits,
green leafy vegetables, and canned salmon and sardines that contain bones.
DIF: Cognitive Level: Application REF: Page 63
TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse
offer to alleviate this symptom?
a. Eat three well-balanced meals per day and limit snacks.
b. Drink a full glass of fluid at the beginning of each meal.
c. Have crackers handy at the bedside, and eat a few before getting out of bed.
d. Eat a bland diet and avoid concentrated sweets.
ANS: C
The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate
nausea during pregnancy.
DIF: Cognitive Level: Application REF: Page 68
OBJ: 10 TOP: Common Discomforts in Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurses
initial action?
a. Assess food intake.
b. Weigh the patient again.
c. Take the blood pressure.
d. Notify the physician.
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ANS: C
The marked weight gain may be an indication of gestational hypertension. The blood pressure should be
assessed before notifying the physician.
DIF: Cognitive Level: Application REF: Page 56
TOP: Gestational Hypertension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse
replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food
can the nurse recommend?
a. Fried fish
b. Olive oil
c. Red meat
d. Leafy green vegetables
ANS: C
Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the
DHA.
DIF: Cognitive Level: Application REF: Page 58
TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. The nurse encourages adequate intake of folic acid for women of childbearing age before and during
pregnancy. What is folic acid thought to decrease the incidence of in fetal development?
a. Structural heart defects
b. Craniofacial deformities
c. Limb deformities
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d. Neural tube defects
ANS: D
Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly.
DIF: Cognitive Level: Knowledge REF: Page 48
OBJ: 8 TOP: Nutrition for Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive
sign of pregnancy?
a. Amenorrhea
b. Uterine enlargement
c. HCG detected in the urine
d. Fetal heartbeat
ANS: D
Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by
ultrasound, and fetal movements felt by the examiner.
DIF: Cognitive Level: Knowledge REF: Page 53
TOP: Physiological Changes During Pregnancy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age
can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope?
a. 4 weeks
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b. 12 weeks
c. 18 weeks
d. 24 weeks
ANS: C
The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy.
DIF: Cognitive Level: Knowledge REF: Page 53
TOP: Physiological Changes During Pregnancy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the
nurses best response?
a. You may notice the baby moving around the 4th or 5th month.
b. Quickening varies with every woman.
c. Youll feel something by the end of the first trimester.
d. The baby will be big enough for you to feel in your 8th month.
ANS: A
Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation.
DIF: Cognitive Level: Knowledge REF: Page 52
TOP: Physiological Changes During Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. A pregnant woman inquires about exercising during pregnancy. What information should the nurse include
when planning to educate this woman?
a. Exercise elevates the mothers temperature aNnU
d Rim
s .fCeO
taM
l circulation.
SIpNroGvTeB
b. Exercise increases catecholamines, which can prevent preterm labor.
c. A regular schedule of moderate exercise during pregnancy is beneficial.
d. Pregnant women should limit water intake during exercise.
ANS: C
In general, moderate exercise several times a week, from the 8th week through delivery, is advised during
pregnancy.
DIF: Cognitive Level: Comprehension REF: Page 65
TOP: Exercise During Pregnancy KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and
counseling for adolescents different from other age populations?
a. A pregnant adolescent is experiencing two major life transitions at the same time.
b. Adolescents who get pregnant are more likely to have other chronic health problems.
c. Adolescents are at greater risk for multifetal pregnancies.
d. At this age, a pregnant adolescent will accept the nurses advice.
ANS: A
The pregnant adolescent must cope with two of lifes most stress-laden transitions simultaneously: adolescence
and parenthood.
DIF: Cognitive Level: Comprehension REF: Page 72
TOP: Psychological Adaptations to Pregnancy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
20. At what age is a woman who becomes pregnant for the first time described as an elderly primip?
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a. After 25 years old
b. After 28 years old
c. After 30 years old
d. After 35 years old
ANS: D
A woman over the age of 35 who becomes pregnant for the first time is described as an elderly primip.
DIF: Cognitive Level: Knowledge REF: Page 72
TOP: Elderly Primip KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physical Adaptation
21. The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the
appropriate term for this sign?
a. Chadwicks
b. Hegars
c. McDonalds
d. Goodells
ANS: D
Goodells sign is one of the probable signs of pregnancy and describes a softened cervix and vagina.
DIF: Cognitive Level: Knowledge REF: Page 52
TOP: Goodells Sign KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physical Adaptation
22. When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell
disease. Given this information, what lab test can the nurse anticipate the physician will order?
a. Endovaginal ultrasound
b. Pap test
NURSINGTB.COM
c. Complete blood count
d. Hemoglobin electrophoresis
ANS: D
Hemoglobin electrophoresis identifies presence of sickle cell trait or disease (in women of African or
Mediterranean descent). It is ordered in the first trimester, if indicated.
DIF: Cognitive Level: Comprehension REF: Page 49
OBJ: 3 TOP: Prenatal laboratory tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
23. A pregnant woman is attending her second postpartum visit. Prenatal lab work indicates she is not immune
to the rubella virus. What is the most appropriate nursing intervention?
a. Provide the rubella vaccine as ordered by the physician immediately.
b. Inform the woman she should receive the vaccine in the hospital after delivery.
c. Hold all immunizations until 1 month postpartum.
d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally.
ANS: B
The rubella vaccine is contraindicated during pregnancy. A woman should be instructed to avoid pregnancy for
at least 1 month following rubella immunization. It is not necessary to hold all immunizations until 1 month
postpartum.
DIF: Cognitive Level: Application REF: Page 75
TOP: Immunizations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
24. A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse
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37
explain as the most likely cause of this symptom?
a. Supine hypotension syndrome
b. Gestational diabetes
c. Pregnancy-induced hypertension
d. Malnutrition
ANS: A
Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the
woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness,
dizziness, and agitation.
DIF: Cognitive Level: Comprehension REF: Page 56
TOP: Physiological Changes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
MULTIPLE RESPONSE
25. A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What
would the nurse recommend that the patient do during the flight? (Select all that apply.)
a. Wear tight-fitting clothing to promote venous return.
b. Eat a large meal before boarding the flight.
c. Request a seat with greater leg room.
d. Drink at least 4 ounces of water every hour.
e. Get up and walk around the plane frequently.
ANS: C, D, E
Because of the increase in clotting potential, the pregnant patient is prone to a thromboembolism. Adequate
hydration, frequent position changes, and movement decrease the risk.
DIF: Cognitive Level: Application REF: PageN6U7RSINGTB.COM
TOP: Flight Precautions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
26. The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax.
What does this result in? (Select all that apply.)
a. Waddling gait
b. Joint instability
c. Urinary frequency
d. Back pain
e. Aching in cervical spine
ANS: A, B
A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are
related to the enlarging uterus with its attendant weight.
DIF: Cognitive Level: Comprehension REF: Page 58
TOP: Joint Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. The nurse assesses the progress from the announcement stage of fatherhood to the acceptance stage when
the patient reports which actions by the father? (Select all that apply.)
a. Goes fishing every afternoon
b. Has revised his financial plan
c. Spends leisure time with his friends
d. Traded his sports car for a sedan
e. Helped select a crib
ANS: B, D, E
Active planning for an infant is an indication of the acceptance stage. Concentration on a hobby and spending
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time away from home are indicators of nonacceptance.
DIF: Cognitive Level: Comprehension REF: Page 71
TOP: Stages of Fatherhood KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28. What nursing interventions are appropriate for the prenatal patient in terms of prenatal care? (Select all that
apply.)
a. Offer nutritional counseling.
b. Reinforce responsibility of parenthood.
c. Reduce risk factors.
d. Improve health practices.
e. Make financial arrangements for delivery.
ANS: A, B, C, D
Nutritional counseling, reinforcing and discussing the responsibility of parenthood, reducing risk factors for
the pregnant woman and the fetus, and improving health practices are all goals of prenatal care.
DIF: Cognitive Level: Comprehension REF: Page 47
TOP: Goals of Prenatal Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
29. The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy?
(Select all that apply.)
a. Showing off her sonogram photos
b. Ambivalence about pregnancy
c. Emotional and labile mood
d. Focusing on her infant
e. Fatigue
NURSINGTB.COM
ANS: A, B, C, E
Showing off photos, feeling ambivalence about the pregnancy, fragile emotions, and fatigue and sleepiness are
all characteristic of behaviors seen in the first trimester. Women are not focused on their infant; they are
focused on themselves and the physical changes they are experiencing.
DIF: Cognitive Level: Comprehension REF: Page 70
TOP: Behaviors of First Trimester KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
30. The number of years between menarche and the date of conception is known as
age.
ANS:
gynecological
Gynecological age is a term that refers to the number of years between the starting of the menses and the date
of conception.
DIF: Cognitive Level: Comprehension REF: Page 64
TOP: Gynecological Age KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The nurse reminds the prenatal patient that she should add
fetus.
ANS:
300
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kcal to her daily intake to nourish the
INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
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The recommended dietary intake increase is 300 kcal a day.
DIF: Cognitive Level: Comprehension REF: Page 62
TOP: Nutrition During Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32. The patient confesses to eating crushed ice 10 or 12 times daily. The nurse assesses this behavior as
.
ANS:
pica
Pica is the craving and ingestion of nonfood substances such as clay, crushed ice, and ashes.
DIF: Cognitive Level: Comprehension REF: Page 64
TOP: Pica KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33. The nurse is aware that
maneuver can assess the position and presentation of the fetus.
ANS:
Leopolds
Leopolds maneuver assesses the position and the presentation of the fetus by palpation.
DIF: Cognitive Level: Comprehension REF: Page 50
TOP: Leopolds Maneuver KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
34. Fathers go through phases similar to the expectant mother. Place the following phases in order from first to
last. Put a comma and space between each ansNwUeR
rS
chIN
oiGcT
e B(a.C
, bO,M
c, d, etc.)
a. Focus phase
b. Announcement phase
c. Adjustment phase
ANS:
B, C, A
For fathers, the announcement phase begins when pregnancy is confirmed. The second phase of the fathers
response is the adjustment phase. The third phase of the fathers response is the focus phase, in which active
plans for participation in the labor process, birth, and change in lifestyle result in the partner feeling like a
father.
DIF: Cognitive Level: Comprehension REF: Page 72
TOP: Impact on the Father KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Developmental Stages and Transitions
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Chapter 05: Nursing Care of Women with Complications During
Pregnancy
MULTIPLE CHOICE
1. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that
hyperemesis gravidarum is distinguished from morning sickness?
a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.
ANS: B
Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with
hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.
DIF: Cognitive Level: Comprehension REF: Page 85
OBJ: 4 TOP: Hyperemesis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some
tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms?
a. Inevitable abortion
b. Incomplete abortion
c. Complete abortion
d. Missed abortion
ANS: B
NURSINGTB.COM
Signs and symptoms of an incomplete abortion are similar to those of an inevitable abortion, but some tissue is
passed.
DIF: Cognitive Level: Comprehension REF: Page 90
OBJ: 4 TOP: Incomplete Abortion
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed
abortion. What is the most appropriate statement by the nurse?
a. There is usually something wrong with the fetus when this happens early in pregnancy.
b. Now there. You can try to conceive on your next cycle.
c. Im here if you need to talk.
d. You are young and strong. I know you can have a healthy pregnancy.
ANS: C
An effective technique when communicating with a woman experiencing pregnancy loss is to say, Im here if
you need to talk. The nurse listens and acknowledges the womans grief.
DIF: Cognitive Level: Application REF: Page 91
TOP: Dilation and Evacuation (D&E) KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by
abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman
understands the explanation of an ectopic pregnancy?
a. The chorionic villi develop vesicles within the uterus.
b. The placenta develops in the lower part of the uterus.
c. The fetus dies in the uterus during the first half of the pregnancy.
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d. The embryo is implanted in the fallopian tube.
ANS: D
Ectopic pregnancy occurs when the fertilized ovum is implanted outside of the uterine cavity.
DIF: Cognitive Level: Comprehension REF: Page 92
TOP: Ectopic Pregnancy KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical
os. What does the nurse understand best describes this condition?
a. Low-lying placenta
b. Marginal placenta previa
c. Partial placenta previa
d. Total placenta previa
ANS: D
A total placenta previa describes a condition in which the placenta completely covers the cervical opening.
DIF: Cognitive Level: Comprehension REF: Page 94
TOP: Placenta Previa KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. What symptom presented by a pregnant women is indicative of abruptio placentae?
a. Painless vaginal bleeding
b. Uterine irritability with contractions
c. Vaginal bleeding and back pain
d. Premature rupture of membranes
ANS: C
NURSINGTB.COM
Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.
DIF: Cognitive Level: Knowledge REF: Page 95
TOP: Abruptio Placenta KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. What situation would concern the nurse about the presence of Rh incompatibility?
a. Rh-negative mother, Rh-positive fetus
b. Rh-positive mother, Rh-negative fetus
c. Rh-negative mother, Rh-negative fetus
d. Rh-positive mother, Rh-positive fetus
ANS: A
Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.
DIF: Cognitive Level: Analysis REF: Page 101
TOP: Rh Incompatibility KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh
antibodies from forming?
a. Rh immune globulin during labor
b. Intrauterine transfusions with O-negative blood
c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant
d. Rh immune globulin now and again in the last trimester
ANS: C
An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after
the birth of an Rh-positive infant or abortion.
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DIF: Cognitive Level: Comprehension REF: Page 101
TOP: Rh Incompatibility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios
with each pregnancy. What does the nurse recognize these factors highly suggest?
a. Toxoplasmosis
b. Abruptio placentae
c. Hydatidiform mole
d. Diabetes mellitus
ANS: D
Large (macrosomic) infants over 9 pounds are linked to gestational diabetes.
DIF: Cognitive Level: Comprehension REF: Page 102
TOP: Diabetes Mellitus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism
in what way?
a. Placental hormones increase the resistance of cells to insulin.
b. Insulin cells cannot meet the bodys demands as the womans weight increases.
c. There is a decreased production of insulin during pregnancy.
d. The speed of insulin breakdown is decreased during pregnancy.
ANS: A
Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.
DIF: Cognitive Level: Knowledge REF: Page 102
TOP: Diabetes Mellitus KEY: Nursing ProcesN
sU
SR
teSpI:NIG
mTpB
le.m
enMtation
CO
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to take insulin
during pregnancy?
a. Insulin can cross the placental barrier to the fetus.
b. Insulin does not cross the placental barrier to the fetus.
c. Oral agents do not cross the placenta.
d. Oral agents are not sufficient to meet maternal insulin needs.
ANS: B
Oral hypoglycemic agents are not used during pregnancy because they can cross the placenta, possibly
resulting in fetal birth defects or hypoglycemia.
DIF: Cognitive Level: Comprehension REF: Page 103
OBJ: 5 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
12. A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that
her infant will also contract hepatitis B. What will the nurse explain to this woman?
a. The infant will be given a single dose of hepatitis immune globulin after birth.
b. The infant will be able to use the antibodies from the immunizations given to the patient before delivery.
c. The infant will not have hepatitis B because the virus does not pass through the placental barrier.
d. The infant will be immune to hepatitis B because of the mothers infection.
ANS: A
The infant will be given immune globulin immediately after birth for temporary immunity followed by
hepatitis B vaccine. Immunization is not recommended for women who are pregnant.
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DIF: Cognitive Level: Comprehension REF: Page 110
OBJ: 5 TOP: Hepatitis B KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
13. What will the nurse begin with when asking a patient about drug use during a prenatal history?
a. Do you smoke, drink alcohol, or use drugs?
b. Do you ever use prescription or street drugs?
c. What over-the-counter and prescription drugs have you taken in the past 3 months?
d. We need to know if you take drugs so we can help your baby.
ANS: C
Screening for drug use should begin in a nonthreatening way by asking about prescription and OTC
medications and how the information can help provide safe and appropriate prenatal care.
DIF: Cognitive Level: Application REF: Page 114
OBJ: 6 TOP: Interviewing Relative to Drug Use
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid
retention suggestive of this complication?
a. Abdominal enlargement
b. Facial swelling
c. Sudden weight gain
d. Swelling of the feet and ankles
ANS: C
Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs,
and hands follow weight gain.
NURSINGTB.COM
DIF: Cognitive Level: Knowledge REF: Page 97
TOP: Hypertension KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report
immediately?
a. Diarrhea
b. Urticaria
c. Blurred vision
d. Backache
ANS: C
Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for
effective intervention to prevent preeclampsia and convulsion.
DIF: Cognitive Level: Application REF: Page 97
TOP: Hypertension KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home
health nurse make the first priority?
a. Activity restriction
b. Balanced nutrition
c. Increased fluid intake to ensure adequate hydration
d. Instruction about the effect of diuretics
ANS: A
Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and
enhancing fetal oxygenation.
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DIF: Cognitive Level: Application REF: Page 98
TOP: Hypertension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the
objective of magnesium sulfate therapy for this patient?
a. To prevent convulsions
b. To promote diaphoresis
c. To increase reflex irritability
d. To act as a saline cathartic
ANS: A
Magnesium sulfate is a central nervous system depressant given to prevent seizures.
DIF: Cognitive Level: Knowledge REF: Page 98
TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18. The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What
is the most appropriate nursing intervention?
a. Count respirations and report a rate of less than 12 breaths/min.
b. Count respirations and report a rate of more than 20 breaths/min.
c. Check blood pressure and report a rate of less than 100/60 mm Hg.
d. Monitor urinary output and report a rate of less than 100 mL/hr.
ANS: A
Excessive magnesium sulfate may cause respiratory depression.
DIF: Cognitive Level: Application REF: Page 99
OBJ: 4 TOP: Magnesium Sulfate
NURSINGTB.COM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
19. What drug will the nurse plan to have available for immediate IV administration whenever magnesium
sulfate is administered to a maternity patient?
a. Ergonovine maleate (Ergotrate)
b. Oxytocin
c. Calcium gluconate
d. Hydralazine (Apresoline)
ANS: C
Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a
woman receives magnesium sulfate.
DIF: Cognitive Level: Comprehension REF: Page 99
TOP: Calcium Gluconate KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
20. A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, Will I be able to deliver
vaginally? What explanation by the nurse is the most appropriate?
a. Yes, you can deliver vaginally until 36 weeks.
b. A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done.
c. A cesarean section is performed when the mother has a total placenta previa.
d. There is no reason why you cannot have a vaginal delivery.
ANS: C
A cesarean delivery is done for a partial or total placenta previa.
DIF: Cognitive Level: Application REF: Page 96
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TOP: Placenta Previa KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus.
What can result from maternal rubella during pregnancy?
a. Facial abnormalities
b. Mental retardation
c. Liver failure
d. Limb deformities
ANS: B
Rubella can have devastating effects on the developing fetus. Some effects of rubella on the embryo or fetus
include microcephaly, mental retardation, cardiac defects, cataracts, and deafness.
DIF: Cognitive Level: Knowledge REF: Page 110
TOP: Rubella KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis?
a. Frequency and urgency of urination
b. Nausea and weight loss
c. Burning sensation when voiding
d. Tenderness in the flank area
ANS: D
Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills,
flank pain or tenderness, nausea, and vomiting.
DIF: Cognitive Level: Comprehension REF: Page 113
TOP: Pyelonephritis KEY: Nursing Process SN
teU
p:RD
ecOtM
ion
SIaNtaGC
ToBl.lC
MSC: NCLEX: Physiological Integrity: Reduction of Risk
23. The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this
patient?
a. Flat on her back with knees flexed to help prevent hemorrhage
b. On her side to prevent supine hypotension
c. In the semi-Fowlers position to prevent supine hypotension
d. In the knee-chest position to reduce pressure on the placenta
ANS: B
The prenatal patient with placenta previa is best placed on her side with a pillow for support. This position not
only reduces stress on the placenta but also reduces the possibility of supine hypotension.
DIF: Cognitive Level: Application REF: Page 95
TOP: Placenta Previa KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. The young prenatal patient with gestational diabetes mellitus (GDM) says, I am frightened that I will have
to deal with insulin injections for the rest of my life. What is the best response by the nurse?
a. After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so
much simpler than insulin injections.
b. Have you considered an insulin pump?
c. After a while those insulin injections wont seem so bad.
d. It will most likely resolve 6 weeks or so after the baby is born.
ANS: D
GDM usually resolves by 6 weeks after delivery.
DIF: Cognitive Level: Application REF: Page 103
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TOP: GDM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
25. The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks gestation. What
intervention will the nurse implement before this diagnostic test?
a. Instruct the patient to take nothing by mouth after midnight the night before the test.
b. Initiate an IV.
c. Encourage the patient to drink 1 to 2 quarts of water before the test.
d. Instruct the patient to remove all jewelry.
ANS: C
Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use
a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full
bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination).
DIF: Cognitive Level: Application REF: Page 86
OBJ: 2 TOP: Diagnostic Tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
MULTIPLE RESPONSE
26. The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse
assess for in the newborn? (Select all that apply.)
a. Meconium ileus
b. Diarrhea
c. Hypoglycemia
d. Muscle tremors
e. Urine retention
NURSINGTB.COM
ANS: C
The fetus responds to the hyperglycemia from the mothers blood and produces increased insulin. This insulin
may cause hypoglycemia in the infant after it is no longer exposed to the mothers blood.
DIF: Cognitive Level: Application REF: Page 103
OBJ: 5 TOP: Hypoglycemia in Macrosomic Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27. The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included
in this classification? (Select all that apply.)
a. Toxoplasmosis
b. Toxemia
c. Cytomegalovirus
d. Rubella
e. Herpes simplex
ANS: A, C, D, E
The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.
DIF: Cognitive Level: Knowledge REF: Page 109
TOP: TORCH Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
28. The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might
result in which problems? (Select all that apply.)
a. Disruption of family roles
b. Financial pressures
c. Excessive attachment to infant
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d. Frustration with activity restriction
e. Alteration in child care practices
ANS: A, B, D, E
High-risk pregnancies may produce problems such as disruption of family roles, financial pressures, delayed
attachment to the infant, alteration in child care practices, and frustration with activity restriction.
DIF: Cognitive Level: Comprehension REF: Page 118
TOP: Impact of High-Risk Pregnancies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
29. A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What
should the ED nurse offer the patient? (Select all that apply.)
a. Privacy
b. An opportunity to hold the infant
c. Materials about support groups
d. A memento (footprint or lock of hair)
e. A warm beverage
ANS: A, B, C, D
The patient should be offered privacy, an opportunity to hold the infant, support group information, and a
memento. A warm beverage is not a priority at this time.
DIF: Cognitive Level: Application REF: Page 118
TOP: Stillborn Infant KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
30. What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia
and has been placed on iron supplements? (Select all that apply.)
a. Citrus fruits enhance absorption of iron. NURSINGTB.COM
b. Bran products support iron deficiency.
c. Milk will disguise the taste of the iron.
d. The iron therapy will continue for about 3 months.
e. Tea should be avoided while taking iron.
ANS: A, D, E
Calcium, bran, and milk interfere with the absorption of iron. Vitamin C helps with the absorption of iron, the
therapy usually lasts 3 months, and the tannic acid in tea does interfere with the absorption of iron.
DIF: Cognitive Level: Application REF: Page 108
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
31. The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection
for what reasons? (Select all that apply.)
a. Vaginal organisms can invade the placenta.
b. The undernourished placenta becomes necrotic.
c. The amniotic fluid can become infected.
d. The placenta is an excellent growth medium.
e. The misplaced placenta weakens the uterine wall.
ANS: A, D
Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the
nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus will cause
postpartum hemorrhage rather than infection.
DIF: Cognitive Level: Comprehension REF: Page 94
TOP: Infection with Placenta Previa KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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32. The nurse is obtaining history and physical information on a new patient attending her first prenatal visit.
After recording current height, weight, and BMI, it is determined that the patient is obese. What complications
related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.)
a. Gestational diabetes
b. RH Incompatibility
c. Hypertension
d. Pre-eclampsia
e. Infection
ANS: A, C, D
The obese woman who is pregnant has a high risk for developing complications during pregnancy such as
gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems.
DIF: Cognitive Level: Comprehension REF: Page 109
TOP: Obesity KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
33. A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is
battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing
actions are appropriate for the nurse to implement? (Select all that apply.)
a. Tell the husband that authorities will be notified immediately.
b. Provide privacy for the assessment.
c. Determine if children are being hurt.
d. Communicate in a non-judgmental way.
e. Determine factors that increase the risk of injury.
ANS: B, C, D, E
The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors
that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior
use of a weapon, or violent behavior by the abNuU
seRr SoIuNtsGidTeBt.C
heOhMome. The nurse also determines whether
children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she
intends to leave.
DIF: Cognitive Level: Application REF: Page 116
OBJ: 7 TOP: Battering KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Injury Prevention
COMPLETION
34. The nurse cautions that the consumption of as few as
lead to the loss of fetal brain cells.
alcoholic drink(s) during pregnancy can
ANS:
two
Studies have shown that even as few as two alcoholic drinks consumed during pregnancy can cause loss of
fetal brain cells. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor.
DIF: Cognitive Level: Comprehension REF: Page 116
OBJ: 5 TOP: Fetal Alcohol Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
35. The nurse explains that
is a procedure in which an incompetent cervix is sutured closed to
prevent its opening when the fetus presses against it.
ANS:
cerclage
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Cerclage is the procedure that sutures the cervix closed to prevent its opening when the fetus presses against it.
DIF: Cognitive Level: Knowledge REF: Page 89
TOP: Cerclage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
36.
have a high mortality rate.
is the leading cause of perinatal infections tha
ANS:
Group B streptococcus (GBS)
Group B streptococcus (GBS) is a leading cause of perinatal infections that have a high neonatal mortality rate.
The organism can be found in the womans rectum, vagina, cervix, throat, or skin.
DIF: Cognitive Level: Knowledge REF: Page 112
TOP: Perinatal Infections KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Antepartum and Newborn Care
37. A(n)
consists of a group of five fetal assessments: fetal heart rate
and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand),
and volume of amniotic fluid.
ANS:
biophysical profile
A biophysical profile consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST),
fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic
fluid.
DIF: Cognitive Level: Knowledge REF: PageN8U
7 RSINGTB.COM
OBJ: 2 TOP: Diagnostic tests
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Heath Promotion and Maintenance: Prenatal Care
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Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
MULTIPLE CHOICE
1. What does the nurse note when measuring the frequency of a laboring womans contractions?
a. How long the patient states the contractions last
b. The time between the end of one contraction and the beginning of the next
c. The time between the beginning and the end of one contraction
d. The time between the beginning of one contraction and the beginning of the next
ANS: D
The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the
next contraction.
DIF: Cognitive Level: Comprehension REF: Page 126
TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Why is the relaxation phase between contractions important?
a. The laboring woman needs to rest.
b. The uterine muscles fatigue without relaxation.
c. The contractions can interfere with fetal oxygenation.
d. The infant progresses toward delivery at these times.
ANS: C
Blood flow from the mother into the placenta gradually decreases during contractions. During the interval
between contractions, the placenta refills with oxygenated blood for the fetus.
DIF: Cognitive Level: Comprehension REF: Page 127
OBJ: 6 TOP: Interval KEY: Nursing Process SNtU
epR:SNIN
/AGTB.COM
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What contraction duration and interval does the nurse recognize could result in fetal compromise?
a. Duration shorter than 30 seconds, interval longer than 75 seconds
b. Duration shorter than 90 seconds, interval longer than 120 seconds
c. Duration longer than 90 seconds, interval shorter than 60 seconds
d. Duration longer than 60 seconds, interval shorter than 90 seconds
ANS: C
Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may
reduce fetal oxygen supply.
DIF: Cognitive Level: Comprehension REF: Page 128
OBJ: 9 TOP: Contraction/Fetal Compromise
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. Vaginal examination reveals the presenting part is the infants head, which is well flexed on the chest. What
is this presentation?
a. Vertex
b. Military
c. Brow
d. Face
ANS: A
In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.
DIF: Cognitive Level: Comprehension REF: Page 128
OBJ: 9 TOP: Fetal Position
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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
a. Fetal distress
b. Fetal maturity
c. Intact gastrointestinal tract
d. Dehydration in the mother
ANS: A
Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of
fetal compromise.
DIF: Cognitive Level: Comprehension REF: Page 143
TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetuss hips are flexed and
the knees are extended. How would the nurse record this presentation?
a. Complete breech
b. Frank breech
c. Double footling
d. Buttocks presentation
ANS: B
When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the
shoulders.
DIF: Cognitive Level: Application REF: Page 129
OBJ: 9 TOP: Components of the Birth ProcesN
s URSINGTB.COM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows
that what indicates the beginning of true labor?
a. Contractions that are relieved by walking
b. Discomfort in the abdomen and groin
c. A decrease in vaginal discharge
d. Regular contractions becoming more frequent and intense
ANS: D
In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more
intense.
DIF: Cognitive Level: Application REF: Page 137
OBJ: 7 TOP: Initiation of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should
go to the hospital. What is the nurses most informative response?
a. When you feel increased fetal movement
b. When contractions are 10 minutes apart
c. When membranes have ruptured
d. When abdominal or groin discomfort occurs
ANS: C
Ruptured membranes are an indication that the woman should go to the hospital or birthing center.
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DIF: Cognitive Level: Application REF: Page 134
TOP: Admission to the Hospital or Birth Center
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about
contractions during this stage of labor?
a. They get the infant positioned for delivery.
b. They push the infant into the vagina.
c. They dilate and efface the cervix.
d. They get the mother prepared for true labor.
ANS: C
The first stage of labor describes the time from the onset of labor until full dilation of the cervix.
DIF: Cognitive Level: Comprehension REF: Page 150
OBJ: 6 TOP: First Stage of Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing
coach and the nurse, what does the nurse assess as the most likely explanation for the womans change in
behavior?
a. Labor has progressed to the transition phase.
b. She lacked adequate preparation for the labor experience.
c. The woman would benefit from a different form of analgesia.
d. The contractions have increased from mild to moderate intensity.
ANS: A
If a woman suddenly loses control and becomN
esUiR
rrSitIaNbG
leT, Bsu.CspOeM
ct that she has progressed to the transition stage
of labor.
DIF: Cognitive Level: Analysis REF: Page 150
OBJ: 6 TOP: Transition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. What is the function of contractions during the second stage of labor?
a. Align the infant into the proper position for delivery
b. Dilate and efface the cervix
c. Push the infant out of the mothers body
d. Separate the placenta from the uterine wall
ANS: C
The contractions push the infant out of the mothers body as the second stage of labor ends with the birth of the
infant.
DIF: Cognitive Level: Knowledge REF: Page 150
OBJ: 6 TOP: Second Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. What marks the end of the third stage of labor?
a. Full cervical dilation
b. Expulsion of the placenta and membranes
c. Birth of the infant
d. Engagement of the head
ANS: B
The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.
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DIF: Cognitive Level: Knowledge REF: Page 151
OBJ: 6 TOP: Third Stage of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. Why should the nurse encourage the mother to void during the fourth stage of labor?
a. A full bladder could interfere with cervical dilation.
b. A full bladder could obstruct progress of the infant through the birth canal.
c. A full bladder could obstruct the passage of the placenta.
d. A full bladder could predispose the mother to uterine hemorrhage.
ANS: D
A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and
interferes with contractions.
DIF: Cognitive Level: Comprehension REF: Page 151
OBJ: 6 TOP: Nursing Care Immediately After Birth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. The nurse observes the patient bearing down with contractions and crying out, The baby is coming! What
is the best nursing intervention?
a. Find the physician.
b. Stay with the woman and use the call bell to get help.
c. Send the womans partner to locate a registered nurse.
d. Assist with deep breathing to slow the labor process.
ANS: B
If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call
NURSINGTB.COM
bell.
DIF: Cognitive Level: Application REF: Page 135
TOP: Imminent Birth KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to
20 seconds. What does this pattern indicate?
a. A well-oxygenated fetus
b. Compression of the umbilical cord
c. Compression of the fetal head
d. Uteroplacental insufficiency
ANS: A
Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.
DIF: Cognitive Level: Analysis REF: Page 141
TOP: Fetal Accelerations KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. What is the most appropriate statement from the nurse when coaching the laboring woman with a fully
dilated cervix to push?
a. At the beginning of a contraction, hold your breath and push for 10 seconds.
b. Take a deep breath and push between contractions.
c. Begin pushing when a contraction starts and continue for the duration of the contraction.
d. At the beginning of a contraction, take two deep breaths and push with the second exhalation.
ANS: D
When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a
contraction, and then take another deep breath and push while exhaling.
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DIF: Cognitive Level: Application REF: Page 148
TOP: Instructions for Pushing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. What is the most important nursing intervention during the fourth stage of labor?
a. Monitor the frequency and intensity of contractions.
b. Provide comfort measures.
c. Assess for hemorrhage.
d. Promote bonding.
ANS: C
Immediately after giving birth, every woman is assessed for signs of hemorrhage.
DIF: Cognitive Level: Comprehension REF: Page 153
TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most
appropriate nursing action?
a. Check the fundus for position and firmness.
b. Report to the doctor immediately.
c. Change the pads and chart the time.
d. Time how long it takes to soak one pad.
ANS: A
Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an
acceptable rate for immediate postdelivery.
DIF: Cognitive Level: Application REF: Page 153
TOP: Nursing Postdelivery Hemorrhage KEYN
:U
NR
urSsIiN
ngGT
PB
ro.C
ceOsM
s Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate
with uterine contractions. What is the nurses initial action?
a. Stop the oxytocin infusion.
b. Increase the intravenous flow rate.
c. Reposition the woman on her side.
d. Start oxygen via nasal cannula.
ANS: C
Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations
continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.
DIF: Cognitive Level: Application REF: Page 142
OBJ: 9 TOP: Variable Decelerations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. How should the nurse intervene to relieve perineal bruising and edema following delivery?
a. Place an ice pack on the area for 12 hours.
b. Place a warm pack on the perineal area for 24 hours.
c. Administer aspirin to relieve inflammation.
d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hours followed by a
warm pack after the first 12 to 24 hours after delivery.
DIF: Cognitive Level: Application REF: Page 156
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TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. At 1 and 5 minutes of life, a newborns Apgar score is 9. What does the nurse understand that a score of 9
indicates?
a. The newborn will require resuscitation.
b. The newborn may have physical disabilities.
c. The newborn will have above average intelligence.
d. The newborn is in stable condition.
ANS: D
Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are
evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is
stable.
DIF: Cognitive Level: Comprehension REF: Page 157
OBJ: 10 TOP: Care of the Infant After Birth
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. The husband of a woman in labor asks, What does it mean when the baby is at minus 1 station? After
giving an explanation, what statement by the husband indicates that teaching was effective?
a. Fetal head is above the ischial spines.
b. Fetal head is below the ischial spines.
c. Fetal head is engaged in the mothers pelvis.
d. Fetal head is visible at the perineum.
ANS: A
Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of
the ischial spines. Minus stations are above thN
eU
isR
chSiIaNl G
spTiB
ne.Cs.OM
DIF: Cognitive Level: Comprehension REF: Page 132
OBJ: 1 TOP: Mechanisms of Labor
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most
appropriate nursing diagnosis?
a. Pain related to increasing frequency and intensity of contractions.
b. Fear related to the probable need for cesarean delivery.
c. Dysuria related to prolonged labor and decreased intake.
d. Risk for injury related to hemorrhage.
ANS: D
In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.
DIF: Cognitive Level: Application REF: Page 153
TOP: Nursing Care Immediately After Birth
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24. The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to
stimulate cervical effacement and intensify contractions in the patient?
a. By offering the patient warm fluids to drink
b. By helping the patient to ambulate in the room
c. By seating the patient upright in a straight-back chair
d. By positioning the patient on her right side
ANS: B
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Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
DIF: Cognitive Level: Application REF: Page 137
OBJ: 5 | 7 TOP: Differentiating Between True and False Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
25. What is the best nursing action to implement when late decelerations occur?
a. Reposition the patient to supine
b. Decrease flow of intravenous (IV) fluids
c. Increase oxygen to 10 L/minute
d. Prepare to increase oxytocin drip
ANS: C
The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to
increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine
hypotension.
DIF: Cognitive Level: Application REF: Page 143
TOP: Late Decelerations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26. What is the nurse primarily concerned about maintaining in the initial care of the newborn?
a. Fluid intake
b. Feeding schedule
c. Thermoregulation
d. Parental bonding
ANS: C
Thermoregulation is necessary to keep heat loN
ssUm
mGaT
lB
an.C
dOoM
xygen consumption low. Hypothermia can
RiSnIiN
cause cold stress, which leads to hypoxia.
DIF: Cognitive Level: Comprehension REF: Page 156
TOP: Thermoregulation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
27. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean
section) with this pregnancy. What is the primary concern regarding complications for this patient during labor
and birth?
a. Eclampsia
b. Placental abruption
c. Congestive heart failure
d. Uterine rupture
ANS: D
Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean
births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and
cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring
women, regardless of whether they have had a previous cesarean birth.
DIF: Cognitive Level: Comprehension REF: Page 149
TOP: VBAC KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
28. The physician performs an amniotomy on a laboring woman. What will be the nurses priority assessment
immediately following this procedure?
a. Fetal heart rate
b. Fluid amount
c. Maternal blood pressure
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d. Deep tendon reflexes
ANS: A
The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and
reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have
descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is
not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments
following rupture of membranes.
DIF: Cognitive Level: Application REF: Page 143
TOP: Rupture of Membranes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
29. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which
interventions? (Select all that apply.)
a. Provide for extreme modesty.
b. Assign a male caregiver.
c. Arrange for the husband/partner to participate in labor.
d. Provide adequate pain control.
e. Respect protective amulets.
ANS: A, D, E
Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and
religious amulets. The husband is in attendance but not as a participant. Arabs prefer female caregivers. If a
male is in attendance, then the husband will remain in the room as long as the male is there.
DIF: Cognitive Level: Application REF: Page 123
OBJ: 2 TOP: Cultural Considerations
NURSINGTB.COM
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
30. What are the advantages of a freestanding birth center? (Select all that apply.)
a. Home-like setting
b. Designed for high-risk pregnancies
c. Lower costs
d. Attended by certified obstetricians
e. Immediate emergency access
ANS: A, C
Advantages of a freestanding birth center include a homelike setting and lower costs because the center does
not require expensive departments such as emergency or critical care. Freestanding birth centers are not
designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate
emergency access.
DIF: Cognitive Level: Comprehension REF: Page 122
TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31. What do late decelerations indicate? (Select all that apply.)
a. A nonreassuring pattern
b. Uteroplacental insufficiency
c. Fetal heart depression
d. Cord compression
e. Head compression
ANS: A, B, C
This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged
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decelerations indicate cord compression and early decelerations indicate head compressions.
DIF: Cognitive Level: Comprehension REF: Page 141
TOP: Late Decelerations KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32. A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough
examination and diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms
would lead the nurse to suspect false (prodromal) labor? (Select all that apply.)
a. Leaking of vaginal fluid
b. Contractions intensify with ambulation
c. Pink spotting
d. Painless tightening of abdominal muscles
e. Cervix thick and not effaced
ANS: D, E
Painless tightening of abdominal muscles (Braxton-Hicks contractions) and cervix thick and not effaced lend
to the determination of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes
and is a sign of true labor. Contractions that intensify with ambulation and pink spotting (bloody show) are
signs of true labor.
DIF: Cognitive Level: Comprehension REF: Page 137
OBJ: 7 | 8 TOP: False Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
COMPLETION
33. After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the infant as
ROA; this means that the infants head is
.
NURSINGTB.COM
ANS:
right occiput anterior
Right occiput anterior means that the infants right occiput is toward the anterior aspect of the mothers body.
DIF: Cognitive Level: Knowledge REF: Page 131
OBJ: 9 TOP: Fetal Position
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
34. The nurse explains that the four Ps of the birth process are
.
,
,
, and
ANS:
powers, passenger, passage, psyche
The four interrelated components of the process of labor and birth, called the four Ps, are powers, passenger,
passage, and psyche.
DIF: Cognitive Level: Knowledge REF: Page 122
TOP: Four Ps of the Birth Process KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for
minute(s).
ANS:
1
The FHR is checked for 1 full minute to ensure that the infant is not in distress from cord compression
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resultant from the lost buoyancy.
DIF: Cognitive Level: Application REF: Page 143
TOP: Assessment After Membrane Rupture
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36. The nurse may assist the health care provider in determining the fetal position and presentation by
abdominal palpations called
.
ANS:
Leopolds maneuver
The nurse may assist the health care provider in determining the fetal position and presentation by abdominal
palpations called Leopolds maneuver.
DIF: Cognitive Level: Knowledge REF: Page 136
TOP: Leopolds Maneuver KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
37. A nursing student is observing prenatal exams in the office setting. The health care provider informs the
student that the fetal position is LSA. The student interprets this as a
presentation.
ANS:
breech
LSA is the abbreviation for Left Sacrum Anterior. This is a breech presentation.
DIF: Cognitive Level: Comprehension REF: Page 131
OBJ: 6 TOP: Presentation KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INPG
reTnBat.C
alOCMare
38. Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the seven
mechanisms of labor in sequential order. Put a comma and space between each answer choice (a, b, c, d, etc.)
a. Extension
b. Engagement
c. Descent
d. Flexion
e. Expulsion
f. Internal rotation
g. External rotation
ANS:
C, B, D, F, A, G, E
The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into
the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled.
DIF: Cognitive Level: Comprehension REF: Page 133
OBJ: 6 TOP: Mechanisms of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 07: Nursing Management of Pain During Labor and Birth
MULTIPLE CHOICE
1. A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor
pain. What statement is accurate about a patients expression of pain?
a. It reduces the patients perception of pain.
b. It is intensified by the vertex position of the fetus.
c. It is influenced by culture.
d. It can be completely controlled by nonpharmacological techniques.
ANS: C
Culture influences how women feel about birth and what is an acceptable response to pain.
DIF: Cognitive Level: Comprehension REF: Page 168
TOP: Cultural Influences on Pain KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What chemical substance(s) produced in the body acts as a natural pain reliever?
a. Endorphins
b. Morphine
c. Codeine
d. Atropine
ANS: A
Endorphins are natural body substances that are similar to morphine and may explain why laboring women
need smaller doses of analgesia.
DIF: Cognitive Level: Knowledge REF: Page 167
UR
TOP: Endorphins KEY: Nursing Process StepN
:N
/ASINGTB.COM
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. A nurse instructs a womans labor coach to comfort her by firmly pressing on her lower back. What is this
technique?
a. Sacral pressure
b. Distraction
c. Effleurage
d. Conscious relaxation
ANS: A
Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.
DIF: Cognitive Level: Knowledge REF: Page 167
OBJ: 6 TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the
contraction?
a. Use slow-paced breathing.
b. Hold her breath and push.
c. Blow in short breaths.
d. Use rapid-paced breathing.
ANS: C
If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short
breaths to avoid bearing down.
DIF: Cognitive Level: Application REF: Page 170
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TOP: Stair-Step Breathing Pattern KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth.
What does the nurse recognize these symptoms signify?
a. Hypertension
b. Anxiety
c. Anoxia
d. Hyperventilation
ANS: D
Hyperventilation is sometimes a problem if a woman is breathing rapidly.
DIF: Cognitive Level: Comprehension REF: Page 171
OBJ: 4 TOP: Hyperventilation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. What is the most appropriate nursing action to take when a laboring woman hyperventilates?
a. Help her breathe into her cupped hands.
b. Place her flat on her back.
c. Initiate oxygen at 2 liters via mask.
d. Notify the doctor.
ANS: A
Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for
a few seconds. All of these techniques decrease PCO2.
DIF: Cognitive Level: Application REF: Page 171
OBJ: 4 TOP: Nonpharmacological Pain ManaN
geUm
t GTB.COM
ReSnIN
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
7. A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What
should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?
a. It can cause medication given at later stages to be ineffective.
b. It will have no complications for the mother or infant.
c. It may result in respiratory depression to the newborn.
d. It will speed up labor and increase pain.
ANS: C
The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression.
DIF: Cognitive Level: Comprehension REF: Page 171
OBJ: 7 TOP: Opioids KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
8. What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions?
a. Offer warm liquids to the patient.
b. Encourage the patient to pant.
c. Engage the patient in conversation.
d. Assist the patient to the knee-chest position.
ANS: B
Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt
conversation during contractions. Walking intensifies contractions.
DIF: Cognitive Level: Application REF: Page 170
TOP: Panting KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9. A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient
that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?
a. Nausea and vomiting
b. Vomiting and aspiration
c. Abdominal cramping
d. Intestinal obstruction
ANS: B
The major adverse effect of general anesthesia is aspiration of stomach contents.
DIF: Cognitive Level: Comprehension REF: Page 173
OBJ: 7 TOP: General Anesthesia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
10. What assessment should be taken immediately after the anesthesiologist administers an epidural block to a
laboring woman?
a. Bladder for distention
b. Blood pressure
c. Sensation in the lower extremities
d. Intravenous fluid flow rate
ANS: B
Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also
important but not an initial assessment.
DIF: Cognitive Level: Application REF: Page 173
OBJ: 6 TOP: Epidural Block
NURSINGTB.COM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what
associated side effect of this type of regional anesthesia?
a. Reduced fetal heart rate
b. Long, intense contractions
c. Sudden leg cramps
d. Bladder distention
ANS: D
A side effect of an epidural block is urine retention because the anesthesia interferes with the womans ability to
have an urge to void. The patient may have to be catheterized.
DIF: Cognitive Level: Knowledge REF: Page 173
OBJ: 7 TOP: Epidural Block
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. Which narcotic antagonist is used to reverse narcotic-induced respiratory depression?
a. Hydroxyzine (Vistaril)
b. Phenobarbital
c. Naloxone (Narcan)
d. Nitrous oxide
ANS: C
Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.
DIF: Cognitive Level: Knowledge REF: Page 172
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TOP: Narcotic Antagonist KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13. The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What
nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia?
a. Restrict oral fluids.
b. Keep legs flexed.
c. Walk with assistance as soon as possible.
d. Lie flat for several hours.
ANS: D
The woman would be advised to remain flat for several hours after the block to decrease the chance of
postspinal headache.
DIF: Cognitive Level: Application REF: Page 173
OBJ: 7 TOP: Subarachnoid Block
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a
need for further explanation about the pudendal block?
a. Im having a contraction. Can I get the pudendal block now?
b. Ill get the pudendal block right before I deliver.
c. The nurse midwife will insert the needles into my vagina.
d. It takes a few minutes after the medicine is administered to make me feel numb.
ANS: A
The pudendal block does not block pain from contractions and is given just before birth.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS1I7N3GTB.COM
OBJ: 7 TOP: Pudendal Block
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15. An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little
prenatal care and had no childbirth preparation. She is crying loudly and shouting, Please give me something
for the pain. I cant take the pain! What is the priority nursing diagnosis?
a. Pain related to uterine contractions
b. Knowledge deficit related to the birth experience
c. Ineffective coping related to inadequate preparation for labor
d. Risk for injury related to lack of prenatal care
ANS: A
The most important issue for this woman, at this time, is effective pain management.
DIF: Cognitive Level: Analysis REF: Page 177
OBJ: 3 TOP: Pain as a Priority
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
16. The nurse who encourages the gate control theory of pain control would advise a woman in labor and her
partner to use which nonpharmacological method of pain management?
a. Slow abdominal breathing
b. Guided relaxation
c. Listening to music
d. Massage
ANS: D
According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with
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conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter
fibers and closes the gate.
DIF: Cognitive Level: Analysis REF: Page 166
TOP: Gate Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for
delivery. What is a contraindication to an epidural block?
a. Abnormal clotting
b. Previous cesarean delivery
c. History of migraine headaches
d. History of diabetes mellitus
ANS: A
An epidural block is not used if a woman has abnormal blood clotting.
DIF: Cognitive Level: Comprehension REF: Page 173
OBJ: 7 TOP: Epidural Block
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may
premature bearing down cause?
a. Increased use of oxygen
b. Cervical laceration
c. Uterine rupture
d. Compression of the cord
ANS: B
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Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.
DIF: Cognitive Level: Comprehension REF: Page 170
TOP: Cervical Laceration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. What is the Dick-Read method of childbirth preparation based on?
a. Mild sedation throughout labor
b. Relaxation techniques
c. Skin stimulation
d. Deep massage
ANS: B
The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.
DIF: Cognitive Level: Knowledge REF: Page 168
TOP: Dick-Read Method KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline
respiratory rate is 22 breaths per minute. What should be the patients rate while performing slow breathing?
a. 9
b. 11
c. 15
d. 20
ANS: B
The range of respirations should be no lower than half of the base rate and no more rapid than double the base
rate.
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DIF: Cognitive Level: Comprehension REF: Page 167
OBJ: 5 TOP: Lamaze Method
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. What is the least amount of sensation that one perceives as pain?
a. Tolerance
b. Threshold
c. Level
d. Abatement
ANS: B
Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each
individual.
DIF: Cognitive Level: Knowledge REF: Page 166
TOP: Pain Threshold KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the
need for pain relief?
a. Frequently asking for ice chips
b. Facial grimacing
c. Changing positions in bed
d. Covering her face with her hands
ANS: B
Facial grimacing may be an indicator of unexpressed pain.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS1I7N1GTB.COM
TOP: Nonverbal Pain Expressing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
23. A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurses
best response to explain the frequent blood pressure assessments?
a. They ensure that unsafe levels of hypertension do not occur.
b. They help assess for the need for further pain relief.
c. They monitor the progress of labor.
d. They ensure adequate placental perfusion.
ANS: D
The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading
to fetal hypoxia.
DIF: Cognitive Level: Comprehension REF: Page 173
OBJ: 7 TOP: Disadvantage of Epidural Block
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will
this intervention act to control pain?
a. By increasing endorphin production
b. By facilitating effacement and dilation
c. By producing increasing pain tolerance
d. By stimulation of large nerve fibers
ANS: D
The gate control theory explains how pain impulses reach the brain for interpretation. It supports several
nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-
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diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the
conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and close
the gate to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.
DIF: Cognitive Level: Comprehension REF: Page 166
OBJ: 3 TOP: Nonpharmacological Pain Relief
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
25. When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput
posterior (ROA). What will the nurse anticipate?
a. Urinary retention
b. Severe lower back pain
c. A shorter labor process
d. Nausea
ANS: B
If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mothers sacrum,
resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.
DIF: Cognitive Level: Application REF: Page 168
TOP: Maternal Condition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
26. What typical types of classes are available to help expectant parents prepare for parenthood? (Select all that
apply.)
a. Infant care
b. Breastfeeding
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c. Gestational diabetes
d. Sources of financial aid
e. Yoga
ANS: A, B, C
Prenatal classes include such topics as infant care, breastfeeding, gestational diabetes, exercising, and sibling
and grandparent preparation. Yoga and financial information are not traditional content for prenatal instruction
DIF: Cognitive Level: Knowledge REF: Page 164
OBJ: 2 TOP: Prenatal Classes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
27. What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in
order to reduce pain? (Select all that apply.)
a. First stage breathing
b. Abdominal breathing
c. Fourth stage breathing
d. Modified pace breathing
e. Patterned paced breathing
ANS: A, B, D, E
First stage breathing includes the techniques of modified pace breathing and patterned paced breathing, which
are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus
and reduce pain perception. The fourth stage of labor is the womans recovery stage and does not require a
breathing technique.
DIF: Cognitive Level: Comprehension REF: Page 170
TOP: Breathing Exercises KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28. How does the pain of childbirth differ from other types of pain? (Select all that apply.)
a. Childbirth pain is part of a normal process.
b. Childbirth pain seldom needs narcotic relief.
c. Position changes relieve pain and facilitate delivery.
d. Childbirth pain declines following birth.
e. Childbirth pain is self-limited.
ANS: A, C, D, E
Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process,
can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth
pain requires pharmacological management with narcotics in many cases.
DIF: Cognitive Level: Comprehension REF: Page 166
TOP: Childbirth Pain KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
29. Which are nonpharmacological forms of pain relief? (Select all that apply.)
a. Skin stimulation
b. Diversion and distraction
c. Breathing techniques
d. Exercise
e. Yoga
ANS: A, B, C
Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain
control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain
control.
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DIF: Cognitive Level: Knowledge REF: Page 167
OBJ: 5 TOP: Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30. Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later
stages of pregnancy? (Select all that apply.)
a. Leg lifts
b. Pelvic rock
c. Tailor sitting
d. Sit-ups
e. Shoulder curling
ANS: B, C, E
Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra
weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both
increase intraabdominal pressure.
DIF: Cognitive Level: Comprehension REF: Page 165
OBJ: 6 TOP: Helpful Exercises
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. The nurse is providing a conference on nonpharmacological pain control methods. What major advantages
of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.)
a. They sedate the mother.
b. They do not slow labor.
c. They do not dull the excitement of the birth experience.
d. They do not have the potential to cause allergic reactions.
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e. They do not have to be delayed until labor is well established.
ANS: B, C, D, E
All the options mentioned are benefits of nonpharmacological pain control methods with the exception of
sedating the mother.
DIF: Cognitive Level: Knowledge REF: Page 168
TOP: Advantages of Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
32. The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk
for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are
appropriate for the nurse to implement related to this diagnosis? (Select all that apply.)
a. Assess leg movement and sensation before ambulating.
b. Administer antibiotic as ordered.
c. Observe for signs of impending birth.
d. Provide sacral pressure as needed.
e. Assess fetal position frequently.
ANS: A, C
To prevent the risk for injury related to epidural anesthesia the nurse should asses for movement, sensation,
and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change
positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging,
and/or crowning.
DIF: Cognitive Level: Application REF: Page 179
TOP: Epidural Anesthesia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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33. The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide
patient education. What will the nurse include in the educational plan? (Select all that apply.)
a. Onset is slow.
b. Duration is short.
c. Administration is by mouth.
d. No known side effects.
e. It is not the same drug as sufentanil.
ANS: B, E
Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same
drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.
DIF: Cognitive Level: Comprehension REF: Page 172
OBJ: 8 TOP: Narcotic Analgesia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
COMPLETION
34. The amount of pain a person is willing to endure is referred to as
.
ANS:
pain tolerance
Pain tolerance is the amount of pain a person is willing to endure. Pain threshold is the point at which pain is
perceived. Pain threshold is relatively consistent from person to person, but pain tolerance differs greatly.
DIF: Cognitive Level: Knowledge REF: Page 166
TOP: Pain Tolerance KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. The massage technique that stimulates the large-diameter fibers in order to block impulses from the smalldiameter fibers is
.
ANS:
effleurage
Effleurage stimulates the large-diameter fibers and blocks the pain impulses from the small-diameter fibers.
DIF: Cognitive Level: Comprehension REF: Page 166
OBJ: 6 TOP: Effleurage KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
36. The
, also called the psychoprophylactic method, is the basis of most
childbirth preparation classes in the United States.
ANS:
Lamaze method
The Lamaze method, also called the psychoprophylactic method, is the basis of most childbirth preparation
classes in the United States.
DIF: Cognitive Level: Knowledge REF: Page 168
TOP: Childbirth Preparation KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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Chapter 08: Nursing Care of Women with Complications During Labor
and Birth
MULTIPLE CHOICE
1. What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C.
ANS: C
Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with
fetal compromise.
DIF: Cognitive Level: Application REF: Page 184
TOP: Obstetric ProceduresAmniotomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and
begins to have contractions every 90 seconds. What is the nurses initial action?
a. Stop the oxytocin infusion.
b. Continue the infusion and report the findings to the physician.
c. Turn her on her left side and reassess the contractions.
d. Administer oxygen by mask.
ANS: A
Oxytocin is discontinued if signs of fetal compNrU
om
ssM
ive uterine contractions occur.
RSisIeNo
GrTeBx.cCeO
DIF: Cognitive Level: Application REF: Page 185
TOP: Obstetric ProceduresInduction of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
3. What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
a. Warm compresses to the perineum
b. Cold pack to the perineum
c. Warm sitz bath
d. Elevation of hips to prevent edema
ANS: B
Ice is applied to the perineum to reduce bruising and edema.
DIF: Cognitive Level: Application REF: Page 188
TOP: Obstetric ProceduresLacerations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but
contractions are becoming shorter and less frequent. What is this labor pattern considered?
a. Normal
b. Hypotonic
c. Hypertonic
d. False
ANS: B
The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but
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contractions diminish after the active phase.
DIF: Cognitive Level: Comprehension REF: Page 195
OBJ: 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with
membranes intact. What action by the physician will the nurse anticipate?
a. Perform an amniotomy.
b. Initiate tocolytic drugs.
c. Order a sedative for the patient.
d. Plan to do an emergency cesarean section.
ANS: A
Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the
membranes are intact.
DIF: Cognitive Level: Comprehension REF: Page 184
OBJ: 2 | 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
6. An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?
a. Loss of hair from contact with forceps
b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation
ANS: C
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Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.
DIF: Cognitive Level: Application REF: Page 189
TOP: Obstetric ProceduresForceps Delivery
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The
nurse responds, This condition will resolve itself in a few days. What is the cause?
a. Prolonged pressure against the partially dilated cervix
b. Small leak of fluid through the posterior fontanelle
c. Pressure of the forceps during delivery
d. The effect of the vacuum extractor
ANS: D
The chignon is due to the effect of the vacuum extractor and will disappear in a few days.
DIF: Cognitive Level: Comprehension REF: Page 189
TOP: Chignon KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont
induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is
the lowest Bishop score the patient should have prior to induction?
a. 6
b. 8
c. 10
d. 12
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ANS: A
The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is
recommended by the American Congress of Obstetricians and Gynecologists (ACOG).
DIF: Cognitive Level: Comprehension REF: Page 183
OBJ: 2 TOP: Bishop Scoring for Vaginal Delivery
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
9. A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP).
What position will the nurse promote to encourage fetal rotation and pain relief?
a. Prone with legs supported and give her a back massage
b. Supine with legs bent at the knee
c. Standing with support
d. Sitting up and leaning forward on the over-bed table
ANS: D
A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or
kneel leaning forward on a support.
DIF: Cognitive Level: Application REF: Page 197
OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9
cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief
intervention for a woman in precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block.
c. Stay and breathe with her during contractionNsU. RSINGTB.COM
d. Tell her to bear with it because she is close to delivery.
ANS: C
The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions
to help the woman focus and cope with each contraction.
DIF: Cognitive Level: Application REF: Page 199
OBJ: 6 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
11. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured
spontaneously. What complication should the nurse closely assess for with this patient?
a. Chorioamnionitis
b. Hemorrhage
c. Hypotension
d. Amniotic fluid embolism
ANS: A
Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may
be a consequence of rupture because the barrier to the uterine cavity is broken.
DIF: Cognitive Level: Application REF: Page 200
TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse
would assess for which adverse effect?
a. Maternal tachycardia
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b. Maternal hypertension
c. Fetal bradycardia
d. Fetal hypokalemia
ANS: A
Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose
of propranolol.
DIF: Cognitive Level: Comprehension REF: Page 201
TOP: Preterm Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13. Which statement indicates a woman understands activity limitations for the management of preterm labor?
a. After my shower in the morning, I do the laundry and straighten up the house; then I rest.
b. I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.
c. I have a 2-year-old to care for, but I try to rest as much as I can.
d. I get really bored at home, so I go to the shopping mall for just a little while.
ANS: B
Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify
ways to organize necessary activities and maximize rest.
DIF: Cognitive Level: Comprehension REF: Page 202
TOP: Preterm Labor KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. A student nurse questions the instructor regarding what alteration should be made for the assessment of the
fundus of a new postoperative cesarean section patient. What is the best response?
a. The fundus is not assessed until the second postoperative day.
b. The fundus is assessed by walking fingers fN
roUmRSthIeNG
siT
deB.oCfOthMe uterus to the midline.
c. The fundus is assessed only if large clots appear in lochia.
d. The fundus is assessed only once every shift.
ANS: B
Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal
massage.
DIF: Cognitive Level: Comprehension REF: Page 191
TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15. A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse
position the woman to prevent compression of a prolapsed cord?
a. On her right side with knees flexed
b. On her left side with a pillow placed between her legs
c. On her back with her head lower than the rest of her body
d. Supine with her legs elevated and bent at the knee
ANS: C
The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.
DIF: Cognitive Level: Application REF: Page 203
TOP: Emergencies During ChildbirthProlapsed Umbilical Cord
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16. Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is
beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most
appropriate nursing diagnosis?
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a. Anxiety related to the development of postpartum complications
b. Ineffective individual coping related to unfamiliarity with procedures
c. Risk for ineffective parenting related to emergency cesarean section
d. Grieving related to loss of expected birth experience
ANS: D
Women who have cesarean births usually need greater support than those who have vaginal births. They may
feel grief, guilt, or anger because the expected course of birth did not occur.
DIF: Cognitive Level: Application REF: Page 191
TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17. A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for
the next few weeks. What would the nurse planning discharge instruction teach the woman to do?
a. Report any increase in fetal activity.
b. Notify her obstetrician if she has a temperature above 37.8 C (100 F).
c. Massage her breasts to promote uterine relaxation.
d. Rest in a side-lying Trendelenburg position with hips elevated.
ANS: B
For the woman with premature rupture of membranes (PROM) who is not having labor induced right away,
teaching combines information about infection and preterm labor. The woman should monitor her temperature
and report a temperature greater than 37.8 C (100 F).
DIF: Cognitive Level: Application REF: Page 200
TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. A woman who is 24 weeks pregnant is plaN
ceUdRoSnINaG
n TinBtr.C
avOeM
nous infusion of magnesium sulfate. What side
effect should the nurse inform the patient that she might experience?
a. Nausea and vomiting
b. Headache
c. Warm flush
d. Urinary frequency
ANS: C
Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm
flush with the initiation of the drug.
DIF: Cognitive Level: Knowledge REF: Page 201
TOP: Preterm Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about
delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor?
a. By decreasing a womans pain sensitivity
b. By reducing blood flow to the uterus
c. By increasing the ability to tolerate pain
d. By enhancing maternal pushing through greater muscle tension
ANS: B
Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle
tension that counteracts the expulsion powers of contractions.
DIF: Cognitive Level: Comprehension REF: Page 199
TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance
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20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae
that seems to occur with every breath she takes. What is the best nursing action?
a. Give the pain remedy.
b. Notify the charge nurse immediately.
c. Turn the patient to her back and flex her knees.
d. Suggest that the coach give her a back rub.
ANS: B
Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be
reported immediately.
DIF: Cognitive Level: Application REF: Page 203
TOP: Uterine Rupture KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
21. What does the nurse explain is used to soften the cervix with a cervical ripening agent?
a. Prostaglandin gel insertion
b. Intravenous oxytocin
c. Warm saline douches
d. Nipple stimulation
ANS: A
Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for
uterine contractions.
DIF: Cognitive Level: Knowledge REF: Page 183
TOP: Cervical Ripening KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22. The nurse is caring for a patient who is thrN
eaUtR
enSiInNgGpTreBt.eCrO
mMlabor and has been given glucocorticoids. What
is the purpose of glucocorticoid administration?
a. Prevent infection.
b. Increase fetal lung maturity.
c. Increase blood flow from placenta.
d. Relax the cervix.
ANS: B
Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.
DIF: Cognitive Level: Comprehension REF: Page 201
TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor.
Which laboring patient should the nurse attend to first?
a. 18-year-old primigravida with a fetal breech presentation
b. 25-year-old multigravida with history of previous cesarean section
c. 35-year-old multigravida with history of precipitate birth
d. 16-year-old primigravida with a twin pregnancy
ANS: C
A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather
than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from
the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture,
cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal
pregnancy have associated risk factors, but not as immediate as precipitate birth.
DIF: Cognitive Level: Analysis REF: Page 199
TOP: Precipitate Birth KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect
when caring for this patient?
a. Elevated uterine resting tone
b. Painful and poorly coordinated contractions
c. Implementation of fluid restriction
d. Use of frequent position changes
ANS: D
A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance
contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and
poorly coordinated contractions occur with hypertonic labor.
DIF: Cognitive Level: Comprehension REF: Page 195
TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
25. What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.)
a. Oral temperature of 37 C (99.8 F)
b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
c. Flecks of vernix in the amniotic fluid
d. Low back pain
e. Edematous labia
ANS: B
Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the
other options are normal findings for late pregN
nU
anRcSyI.NGTB.COM
DIF: Cognitive Level: Application REF: Page 184
TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26. What are the rationales for labor induction? (Select all that apply.)
a. Placenta previa
b. Prolapse of cord
c. High station of fetus
d. Maternal diabetes
e. Placental insufficiency
ANS: D, E
Maternal diabetes and placental insufficiency are rationales for induction. The other options are
contraindications for labor induction.
DIF: Cognitive Level: Comprehension REF: Page 183
TOP: Rationales for Labor Induction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
27. Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.)
a. Encouraging the patient to sit upright
b. Assisting the patient to ambulate
c. Stimulating the nipples
d. Offering emotional support
e. Allowing the patient to vent frustration
ANS: A, B, C
Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering
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emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate
more effective labor.
DIF: Cognitive Level: Application REF: Page 185
TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. What complications of overstimulation of uterine contractions may occur? (Select all that apply.)
a. Water intoxication
b. Impaired placental exchange of oxygen and nutrients
c. Increased blood pressure
d. Convulsions
e. Uterine rupture
ANS: A, B, E
The most common complications are impaired placental exchange and uterine rupture, but water intoxication
can occur due to fluid retention.
DIF: Cognitive Level: Comprehension REF: Page 186
TOP: Complication of Oxytocin KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of
uterine contractions? (Select all that apply.)
a. Place a warm, moist washcloth over the breast.
b. Brush the nipples with a dry washcloth.
c. Gently pull on the nipples.
d. Apply suction to the nipples with a breast pump.
e. Press the palms of her hands down on her breasts.
NURSINGTB.COM
ANS: B, C, D
Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all
effective methods of nipple stimulation, which will increase the quality of uterine contractions.
DIF: Cognitive Level: Application REF: Page 185
TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
30. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What
conditions would contraindicate labor induction? (Select all that apply.)
a. Maternal gynecoid pelvis
b. Placenta previa
c. Horizontal cesarean incision
d. Prolapsed cord
e. Gestational diabetes
ANS: B, D
Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvis is the
most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean
incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication
for labor induction.
DIF: Cognitive Level: Comprehension REF: Page 183
TOP: Induction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
31. A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse
anticipate implementing? (Select all that apply.)
a. Insert IV.
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b. Record a baseline fetal heart rate.
c. Explain procedure to patient.
d. Instruct patient to ambulate immediately afterward.
e. Ensure a tocolytic is available.
ANS: A, B, C
The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is
recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine
tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed.
After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for
uterine contractions. Vital signs and fetal heart rate are also recorded.
DIF: Cognitive Level: Application REF: Page 183
OBJ: 3 TOP: Cervical Ripening
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
32. After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an
instillation of a bolus of warm sterile saline into the uterus, which is called
.
ANS:
amnioinfusion
A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.
DIF: Cognitive Level: Knowledge REF: Page 182
TOP: Amnioinfusion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: ReducNtU
ioRnSoIfNR
GiTsk
B.COM
33.
is a lower-than-normal amount of amniotic fluid.
ANS:
Oligohydramnios
Oligohydramnios is a lower amount than normal of amniotic fluid.
DIF: Cognitive Level: Knowledge REF: Page 182
TOP: Amniotic Fluid KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk
34. A(n)
contractions.
is a narrow cone inserted into the cervix to ripen the cervix to increase uterine
ANS:
laminaria
A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.
DIF: Cognitive Level: Knowledge REF: Page 184
TOP: Laminaria KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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79
Chapter 09: The Family After Birth
MULTIPLE CHOICE
1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
a. Increased nasal mucus
b. Increased temperature
c. Active muscle movements
d. High-pitched cry
ANS: D
There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
DIF: Cognitive Level: Comprehension REF: Page 228
TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
a. Well-contracted with its upper border at or just below the umbilicus
b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
c. Relaxed with its upper border level with the umbilicus
d. Relaxed with its upper border two or three fingerbreadths below the umbilicus
ANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a
grapefruit, at the level of the umbilicus.
DIF: Cognitive Level: Comprehension REF: Page 209
TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: PhysiN
olUoR
giScIaNl G
ATdB
ap.CtaOtiM
on
3. What statement made by a new mother indicates she needs additional information about breastfeeding?
a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast.
b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.
c. The baby has been nursing every 2 to 3 hours.
d. If the baby gets fussy between feedings, I give her a bottle of water.
ANS: D
Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 232
OBJ: 14 TOP: BreastfeedingSupplemental Feedings
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus.
What is the most appropriate nursing intervention?
a. Notify the physician.
b. Massage the fundus.
c. Initiate measures that encourage voiding.
d. Position the patient flat.
ANS: B
A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
DIF: Cognitive Level: Application REF: Page 211
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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5. What type of lochia will the nurse assess initially after delivery?
a. Serosa
b. Rubra
c. Alba
d. Vaginalis
ANS: B
The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra
lasts for up to 3 days postpartum.
DIF: Cognitive Level: Knowledge REF: Page 211
TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse
would include what information about lochia?
a. Lochia should disappear 2 to 4 weeks postpartum.
b. It is normal for the lochia to have a slightly foul odor.
c. A change in lochia from pink to bright red should be reported.
d. A decrease in flow will be noticed with ambulation and activity.
ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.
DIF: Cognitive Level: Application REF: Page 212
TOP: Hemorrhage KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What instruction should the nurse teach the postpartum woman about perineal self-care?
a. Perform perineal self-care at least twice a dN
ayU. RSINGTB.COM
b. Cleanse with warm water in a squeeze bottle from front to back.
c. Remove perineal pads from the rectal area toward the vagina.
d. Use cool water to decrease edema of the perineum.
ANS: B
Cleansing from front to back prevents contamination from the rectal area.
DIF: Cognitive Level: Application REF: Page 213
TOP: Perineal Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. A postpartum woman is not immune to rubella. What will the nurse expect?
a. The rubella virus vaccine should be administered before discharge.
b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
c. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
d. No intervention is indicated at this time because the woman is not at risk for rubella.
ANS: A
The woman who is not immune to rubella is immunized in the immediate postpartum period because there is
no danger of her being pregnant.
DIF: Cognitive Level: Comprehension REF: Page 218
TOP: Rubella KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. Which statement indicates the new mother is breastfeeding correctly?
a. I will alternate breasts when feeding the baby.
b. I keep the baby on a 4-hour feeding schedule.
c. I let the baby stay on the first breast only 5 minutes.
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d. I put only the nipple in the babys mouth when I am breastfeeding.
ANS: A
Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and
fat content.
DIF: Cognitive Level: Comprehension REF: Page 233
OBJ: 14 TOP: Breastfeeding
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The nurse is counseling a lactating mother about diet. What would the nurse include with this information?
a. Consume 500 more calories than her usual prepregnancy diet.
b. Eat less meat and more fruits and vegetables.
c. Drink 3 to 4 tall glasses of fluid daily.
d. Eat 1000 more calories than her usual prepregnancy diet.
ANS: A
To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her
prepregnancy diet.
DIF: Cognitive Level: Comprehension REF: Page 239
TOP: BreastfeedingMaternal Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond?
a. A woman will not ovulate in the absence of menstrual flow.
b. Most nonlactating women resume menstruation about 2 months postpartum.
c. Generally, a woman does not ovulate in theNfiUrsRt SfIeN
wGcTyBcl.C
esOaM
fter childbirth.
d. The return of menstruation is delayed when a woman does not breastfeed.
ANS: B
Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 214
TOP: Return of Menses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. In what situation will the physician order RhoGAM?
a. An unsensitized Rh-negative mother has an Rh-positive infant.
b. An Rh-negative mother becomes sensitized.
c. A sensitized infant has a rising bilirubin level.
d. An unsensitized infant exhibits no outward signs.
ANS: A
The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.
DIF: Cognitive Level: Analysis REF: Page 218
TOP: RhoGAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat
loss?
a. Conduction
b. Radiation
c. Evaporation
d. Convection
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ANS: C
Newborns lose heat quickly after birth as fluid evaporates from their bodies.
DIF: Cognitive Level: Comprehension REF: Page 225
OBJ: 2 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. What will the nurses instructions for a new mother to care for the infants umbilical cord include?
a. Keeping the area covered with a sterile dressing
b. Dressing the stump with antibiotic ointment at every diaper change
c. Fastening the diaper low to allow for air circulation
d. Giving the newborn a daily tub bath until the cord falls off
ANS: C
Diaper placement below the umbilical stump allows for drying by air circulation.
DIF: Cognitive Level: Application REF: Page 227
OBJ: 2 TOP: Umbilical Cord Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. A new mother states her preference to formula feed her newborn. What will the nurse planning discharge
instructions tell her to help suppress lactation and promote comfort?
a. Wear a well-fitting bra continuously for several days.
b. Stand in a warm shower, letting the water spray over the breasts.
c. Express small amounts of milk from the breasts several times a day.
d. Massage the breasts when they ache.
ANS: A
NURSINGTB.COM
When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort
from engorgement.
DIF: Cognitive Level: Application REF: Page 239
TOP: Suppression of Lactation KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont
think I did it right. What postpartum psychological stage is this woman most likely in based on this comment?
a. Taking in
b. Taking hold
c. Letting go
d. Settling down
ANS: B
In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In
doing so, she may become critical of her performance.
DIF: Cognitive Level: Analysis REF: Page 221
OBJ: 6 TOP: Postpartum Psychological Stages
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation
17. A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate
nursing response?
a. Ill get you some aspirin to relieve the cramping that you feel.
b. Afterpains are more intense with your first baby.
c. Breastfeeding releases a hormone that causes your uterus to contract.
d. A change of position when youre breastfeeding might help.
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ANS: C
Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to
release oxytocin, which is a hormone that contracts the uterus.
DIF: Cognitive Level: Application REF: Page 210
TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. A new mother has decided not to breastfeed her newborn. What information will the nurse include when
planning to teach the mother about formula feeding?
a. Positioning the bottle so that the nipple is full of formula during the entire feeding
b. Heating the infant formula in a microwave
c. Burping the infant after 4 ounces and again when the bottle is empty
d. Propping a bottle for a feeding
ANS: A
The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.
DIF: Cognitive Level: Comprehension REF: Page 241
OBJ: 17 TOP: Formula Feeding
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section.
How would the nurse proceed with this assessment?
a. Palpate from the midline to the side of the body.
b. Palpate from the symphysis to the umbilicus.
c. Palpate from the side of the uterus to the midline.
d. Massage the abdomen in a circular motion.NURSINGTB.COM
ANS: C
The fundus is checked gently by walking the fingers from the side of the uterus to the midline.
DIF: Cognitive Level: Application REF: Page 218
TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the
woman leads the nurse to determine that the teaching was effective?
a. I can thaw frozen breast milk in the microwave.
b. Ill put enough breast milk for one day in a container.
c. Breast milk can be stored in glass containers.
d. Breast milk can be kept in the refrigerator for up to 3 months.
ANS: C
Breast milk can be safely stored in glass or clear hard plastic containers.
DIF: Cognitive Level: Comprehension REF: Page 238
TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
21. What should the nurse implement for security purposes when bringing the infant from the nursery to the
mother?
a. Ask, Is this your band number?
b. Confirm room number of mother.
c. Ask the mother to identify herself verbally.
d. Check the band number of the infant with that of the mother.
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ANS: D
The nurse should check the band number of the infant with that of the mother by asking the mother to verbally
read the number.
DIF: Cognitive Level: Application REF: Page 225
OBJ: 8 TOP: Security Identification Procedure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
22. Below what blood glucose level is the newborn considered hypoglycemic?
a. Below 70 mg/dL
b. Below 60 mg/dL
c. Below 50 mg/dL
d. Below 40 mg/dL
ANS: D
A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40
mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a
further drop.
DIF: Cognitive Level: Comprehension REF: Page 228
TOP: Hypoglycemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
23. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is
provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has
understood the provided instruction?
a. Patient correctly performed return demonstration.
b. Patient indicated understanding by nodding head with instruction.
c. Patient verbalizes I understand.
NURSINGTB.COM
d. Family member indicates patient understands procedure.
ANS: A
The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If
possible, when discussing sensitive information the interpreter should not be a family member, who might
interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the
patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to
remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of
understanding or agreement.
DIF: Cognitive Level: Application REF: Page 209
TOP: Cultural Influences KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Cultural Awareness
24. A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient
and her husband are grief stricken and request the child be baptized immediately. What is the nurses most
appropriate action?
a. Contact the hospital chaplain.
b. Request the couples clergy.
c. Baptize the newborn.
d. Ask the physician to baptize the newborn.
ANS: C
If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest
is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the
infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. If
there is any doubt as to whether the infant is alive, the baptism is given conditionally: If you are capable of
receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The
physician is attending to the patients immediate health needs.
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DIF: Cognitive Level: Application REF: Page 222
TOP: Grieving Parents KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Grief and Loss
25. A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and
verbalized concern about pain. What is the best suggestion by the nurse?
a. Consider formula feeding for the first few days.
b. Pumping breast milk would be best for now.
c. Take pain medication 30 to 40 minutes prior to nursing.
d. Use the football hold when breastfeeding.
ANS: D
The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no
indication for the woman to formula feed or pump. Some pain medications should not be taken when
breastfeeding.
DIF: Cognitive Level: Application REF: Page 233
OBJ: 12 TOP: Breastfeeding
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
26. Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select
all that apply.)
a. Thin, transparent skin
b. Vernix only in the body creases
c. Folded ear springs back slowly
d. Breast tissue under the nipple
e. Creases over entire sole
NURSINGTB.COM
ANS: A, C
The only signs of preterm are the thin skin and the slowly responding ear.
DIF: Cognitive Level: Application REF: Page 226
TOP: Gestational Age Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions
should be included before, during, and after the shower? (Select all that apply.)
a. Leave abdominal dressing open to air.
b. Position patient with back to water stream.
c. Cover infusion site with rubber glove.
d. Provide a shower chair.
e. Confirm ambulation ability.
ANS: B, C, D, E
The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be
covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back
to the water stream.
DIF: Cognitive Level: Application REF: Page 218
OBJ: 5 TOP: Postpartum Shower
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28. What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select
all that apply.)
a. Abdominal tighteners
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b. Head lift
c. Pelvic tilt
d. Kegel exercises
e. Leg lifts
ANS: A, B, C, D
Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises
are acceptable. Leg lifts are too strenuous early in the postpartum period.
DIF: Cognitive Level: Comprehension REF: Page 217
TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. While instructing a new mother on formula preparations, the nurse would include what types? (Select all
that apply.)
a. Ready-to-feed formula
b. Concentrated liquid formula
c. Powdered formula
d. Cows milk
e. Canned evaporated milk
ANS: A, B, C
Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants
needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable
because they are nutritionally inadequate and stress the kidneys.
DIF: Cognitive Level: Comprehension REF: Page 240
TOP: Formula Choices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
NURSINGTB.COM
30. The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What
interventions will the nurse suggest? (Select all that apply.)
a. Omit newborns favorite feeding first.
b. Eliminate one feeding at a time.
c. Expect the need for comfort feeding.
d. Formula will need to be provided to substitute for feeding.
e. Pump breasts in place of eliminated feeding.
ANS: B, C, D
When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One
feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger
infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated
feeding or the breasts will continue to produce milk.
DIF: Cognitive Level: Comprehension REF: Page 239
TOP: Weaning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
31. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would
document this as a(n)
amount of lochia.
ANS:
moderate
A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge.
DIF: Cognitive Level: Application REF: Page 211
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OBJ: 2 TOP: Estimating Lochia Discharge
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
32. The nurse explains that the three infections that are contraindications to breastfeeding are
,
, and
.
ANS:
human immunodeficiency virus (HIV), hepatitis B, hepatitis C
Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk,
as can the viruses that cause hepatitis B and C.
DIF: Cognitive Level: Comprehension REF: Page 231
TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
33. The hormone responsible for milk production is
.
ANS:
prolactin
During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production.
Following delivery, increased levels of prolactin lead to lactation.
DIF: Cognitive Level: Knowledge REF: Page 232
TOP: Prolactin KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
34. The hormone responsible for milk let-down or ejection from the breasts is
NURSINGTB.COM
ANS:
oxytocin
.
The milk let-down reflex is caused by the hormone oxytocin.
DIF: Cognitive Level: Knowledge REF: Page 232
TOP: Oxytocin KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35.
refers to changes that the reproductive organs, particularly the uterus, undergo after birth to
return to their prepregnancy size and condition.
ANS:
Involution
Involution refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to
their prepregnancy size and condition.
DIF: Cognitive Level: Knowledge REF: Page 209
TOP: Puerperium KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 10: Nursing Care of Women with Complications After Birth
MULTIPLE CHOICE
1. What is the first sign of hypovolemic shock from postpartum hemorrhage?
a. Cold, clammy skin
b. Tachycardia
c. Hypotension
d. Decreased urinary output
ANS: B
Tachycardia is usually the first sign of inadequate blood volume.
DIF: Cognitive Level: Knowledge REF: Page 248
OBJ: 2 TOP: Hypovolemic Shock
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to
pass large clots. What does the nurse recognize these signs indicate?
a. Uterine atony
b. Uterine dystocia
c. Uterine hypoplasia
d. Uterine dysfunction
ANS: A
Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not
compress bleeding vessels.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS2I5N0GTB.COM
TOP: Atony KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected?
a. Teach the patient how to massage the abdomen and then get help.
b. Start IV fluids to prevent hypovolemia and then notify the registered nurse.
c. Begin massaging the fundus while another person notifies the physician.
d. Ask the patient to void and reassess fundal tone and location.
ANS: C
When the uterus is boggy, the nurse should immediately massage it until it becomes firm.
DIF: Cognitive Level: Application REF: Page 250
OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What
should the nurses next assessment be?
a. Fullness of the bladder
b. Amount of lochia
c. Blood pressure
d. Level of pain
ANS: A
Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.
DIF: Cognitive Level: Application REF: Page 251
TOP: Bladder Distention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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5. Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a
boggy uterus. What will the nurse anticipate might be ordered by the physician?
a. Ritodrine
b. Magnesium sulfate
c. Oxytocin
d. Bromocriptine
ANS: C
Oxytocin (Pitocin) is the most common drug ordered to control uterine atony.
DIF: Cognitive Level: Comprehension REF: Page 251
TOP: Oxytocin (Pitocin) for Hemorrhage
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the
nurses most helpful response?
a. Stop breastfeeding until the infection clears.
b. Pump the breasts to continue milk production, but do not give breast milk to the infant.
c. Begin all feedings with the affected breast until the mastitis is resolved.
d. Breastfeeding can continue unless there is abscess formation.
ANS: D
The woman with mastitis can continue to breastfeed unless an abscess forms.
DIF: Cognitive Level: Application REF: Page 256
TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7. A woman had a vaginal delivery two days aNgU
o RaS
ndINiG
sT
prBe.pCaOriM
ng for discharge. What will the nurse plan to
teach the woman to report to help prevent postpartum complications?
a. Fever
b. Change in lochia from red to white
c. Contractions
d. Fatigue and irritability
ANS: A
Increased temperature is a sign of infection. The other choices are normal in the postpartum period.
DIF: Cognitive Level: Application REF: Page 254
TOP: Puerperal Infections KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower
leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect
from these symptoms?
a. Phlebitis
b. Puerperal infection
c. Late postpartum hemorrhage
d. Mastitis
ANS: A
The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum
patient.
DIF: Cognitive Level: Analysis REF: Page 253
TOP: Phlebitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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9. Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of
late postpartum hemorrhage?
a. My discharge would change to red after it has been pink or white.
b. If I have a postpartum hemorrhage, I will have severe abdominal pain.
c. I should be alert for an increase in bright red blood.
d. I would pass a large clot that was retained from the placenta.
ANS: A
When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a
return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.
DIF: Cognitive Level: Comprehension REF: Page 252
TOP: Color Change in Lochia KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and
redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the
probable treatment will involve?
a. Anticoagulants for 6 weeks
b. Application of ice to the affected leg
c. Gentle massage of the affected leg
d. Passive leg exercises twice a day
ANS: A
Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize
the risk of embolism.
DIF: Cognitive Level: Analysis REF: Page 253
TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: PharmNaUcR
olSoIgNicGaTl BT.hCeOraMpies
11. What statement by the patient leads the nurse to determine a woman with mastitis understands treatment
instructions?
a. I will apply cold compresses to the painful areas.
b. I will take a warm shower before nursing the baby.
c. I will nurse first on the affected side.
d. I will empty the affected breast every 8 hours.
ANS: B
Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
DIF: Cognitive Level: Comprehension REF: Page 256
TOP: Mastitis KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time
since I had the baby 3 months ago?
a. This is a normal response for the body after pregnancy. Try to get more rest.
b. Ill bet you will snap out of this funk real soon.
c. Why dont you arrange for a babysitter so you and your husband can have a night out?
d. Lets talk about this further. I am concerned about how you are feeling.
ANS: D
If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are
persistent and pervasive.
DIF: Cognitive Level: Application REF: Page 257
OBJ: 6 | 7 TOP: Depression KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both
legs. What nursing action is the most appropriate to prevent thrombus formation?
a. Have the woman sit in a chair for meals.
b. Monitor vital signs every 4 hours and report any changes.
c. Tell the woman to remain in bed with her legs elevated.
d. Assist the woman with ambulation for short periods of time.
ANS: D
Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the
postpartum woman.
DIF: Cognitive Level: Application REF: Page 253
TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a
fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and
symptoms?
a. Dehydration
b. Hypovolemic shock
c. Endometritis
d. Cystitis
ANS: C
Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are
manifestations of endometritis.
DIF: Cognitive Level: Analysis REF: Page 254
OBJ: 2 TOP: Puerperal Infections
KEY: Nursing Process Step: Data Collection NURSINGTB.COM
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating.
She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause
of this womans symptoms?
a. Bipolar disorder
b. Major depression
c. Postpartum blues
d. Postpartum depression
ANS: B
Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite
disturbances, and sometimes delusions about the infant being dead.
DIF: Cognitive Level: Analysis REF: Page 257
TOP: Major Depression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
16. Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now
that she is here, I cant believe how different my life is from what I expected. What is the best nursing response
to the womans statement?
a. How is your partner adjusting to the change?
b. I hear this from a lot of first-time mothers.
c. Have you told anyone else about your feelings?
d. Tell me how things are different.
ANS: D
The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers
feelings about motherhood and her infant.
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DIF: Cognitive Level: Application REF: Page 257
TOP: Disorders of Mood KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17. After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication
should the nurse be alert for in the immediate postpartum period?
a. Cervical laceration
b. Hematoma
c. Endometritis
d. Retained placental fragments
ANS: B
Delivering a large infant and a prolonged labor are risk factors for hematoma formation.
DIF: Cognitive Level: Analysis REF: Page 251
TOP: Hematoma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic
discomfort. What does the nurse explain is the usual treatment for subinvolution?
a. Uterine massage
b. Oxytocin infusion
c. Dilation and curettage
d. Hysterectomy
ANS: C
Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the
cervix and curettage to remove retained placental fragments from the uterine wall.
DIF: Cognitive Level: Knowledge REF: PageN2U
52RSINGTB.COM
TOP: Subinvolution of the Uterus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on
exertion. What action should the nurse implement based on these symptoms?
a. Notify the charge nurse of a possible upper respiratory infection.
b. Notify the physician of a possible pulmonary embolism.
c. Document expected postpartum mucous membrane congestion.
d. Medicate with antipyretic remedy for elevated temperature.
ANS: B
Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and
temperature elevation is a clue to this possible complication.
DIF: Cognitive Level: Application REF: Page 253
TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm
uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding?
a. Concerned and reports a probable cervical laceration
b. Attentive and massages the uterus to expel retained clots
c. Distressed and reports a possible clotting disorder
d. Satisfied with the normal early postpartum finding
ANS: A
The bright trickle of blood with a firm uterus suggests a cervical laceration.
DIF: Cognitive Level: Application REF: Page 251
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TOP: Laceration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed.
Where does the patient report that the pain is felt?
a. Groin
b. Achilles tendon
c. Top of the foot
d. Calf of the leg
ANS: D
A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign.
Homans sign is suggestive of a deep vein thrombosis.
DIF: Cognitive Level: Comprehension REF: Page 253
TOP: Homans Sign KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL.
What action should the nurse implement?
a. Notify the charge nurse of a possible infection.
b. Prepare to put the patient in isolation.
c. Have the infant removed from the room and returned to the nursery.
d. Assess the patient further.
ANS: D
The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of
20,000 to 30,000 cells/dL is normal in the early postpartum period.
DIF: Cognitive Level: Analysis REF: Page 25N
4URSINGTB.COM
TOP: Elevated WBC KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. A postpartum patient experiences anaphylactic shock. What is the most likely cause?
a. Pulmonary embolism
b. Hypertension
c. Allergy
d. Blood clotting disorder
ANS: C
Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused
by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders.
DIF: Cognitive Level: Comprehension REF: Page 247
TOP: Shock KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24. A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct
this woman is the antidote for warfarin overdose?
a. Vitamin A
b. Vitamin B
c. Vitamin E
d. Vitamin K
ANS: D
The antidote for warfarin overdose is vitamin K.
DIF: Cognitive Level: Knowledge REF: Page 253
TOP: Warfarin KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
25. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the
nurse include in this education session? (Select all that apply.)
a. Hypertension
b. Blood clotting disorders
c. Anemia
d. Infection
e. Postpartum hemorrhage
ANS: B, C, D, E
Hypertension is not a cause for postpartum shock; all the other options can cause shock.
DIF: Cognitive Level: Application REF: Page 247
TOP: Postpartum Shock KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia
on it. What would the nurse expect to find on further assessment? (Select all that apply.)
a. A firm fundus the size of a grapefruit
b. A full bladder
c. Retained placental fragments
d. Vital signs indicative of shock
e. A soft, boggy fundus
ANS: B, E
Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a
uterus that is boggy.
NURSINGTB.COM
DIF: Cognitive Level: Analysis REF: Page 250
TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27. The nurse instructs the postpartum patient that her nutritional intake should include which food(s)
particularly supportive to healing? (Select all that apply.)
a. Legumes
b. Potatoes and pasta
c. Citrus fruits
d. Rice
e. Cantaloupe
ANS: A, C, E
Legumes and foods containing vitamin C are conducive to healing. Starches are not.
DIF: Cognitive Level: Comprehension REF: Page 255
TOP: Foods Conducive to Healing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.)
a. Limit fluid intake to 1 liter per day.
b. Empty both breasts with each feeding.
c. Take warm showers.
d. Wear a supportive bra.
e. Pump breasts to ensure emptying.
ANS: B, C, D, E
Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce
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the risk of mastitis and milk accumulation in the breast.
DIF: Cognitive Level: Comprehension REF: Page 256
TOP: Reduction of the Risk of Mastitis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
29. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse
encourage to increase the acidity of urine? (Select all that apply.)
a. Apricots
b. Cranberry juice
c. Plums
d. Prunes
e. Apples
ANS: A, B, C, D
Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to
increase acidity of urine.
DIF: Cognitive Level: Comprehension REF: Page 254
OBJ: 4 TOP: Urinary Tract Infection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate?
(Select all that apply.)
a. Provision of IV fluids
b. Placement of an indwelling Foley catheter
c. Assessment of oxygen saturation
d. Administration of anticoagulants
e. Blood transfusion
NURSINGTB.COM
ANS: A, B, C, E
Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV
fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes,
and assessment of oxygen saturation. Anticoagulants would not be given.
DIF: Cognitive Level: Application REF: Page 248
TOP: Hypovolemic Shock KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
COMPLETION
31. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this
indicates a blood loss of
mL.
ANS:
15
The weight of 1 g in a perineal pad is equal to 1 mL of blood loss.
DIF: Cognitive Level: Comprehension REF: Page 248
TOP: Weighing Perineal Pad KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32. The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called
.
ANS:
subinvolution
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Subinvolution is the term applied to the uteruss slower than expected return to a nonpregnant state.
DIF: Cognitive Level: Knowledge REF: Page 252
TOP: Subinvolution KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33. A(n) is a collection of blood within the tissues.
ANS:
hematoma
A hematoma is a collection of blood within the tissues.
DIF: Cognitive Level: Knowledge REF: Page 251
TOP: Hematoma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 11: The Nurses Role in Womens Health Care
MULTIPLE CHOICE
1. The nurse is preparing a community education program on preventive health care for women. What common
screening test will the nurse plan on explaining to the women attending the program?
a. Breast examination by a health professional
b. Breast self-examination
c. Breast biopsy
d. Mammography
ANS: D
Mammography is a screening test used to detect breast cancer.
DIF: Cognitive Level: Comprehension REF: Page 260
TOP: Mammography KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman who has a
family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time
for a woman to perform a breast self-examination?
a. A few days before her period
b. During her menstrual period
c. On the last day of menstrual flow
d. One week after the beginning of her period
ANS: D
The best time for BSE is 1 week after the beginning of the menstrual period.
DIF: Cognitive Level: Knowledge REF: PageN2U
60RSINGTB.COM
TOP: Breast Self-Exam KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. A woman asks the nurse, How do oral contraceptives prevent pregnancy? What will the nurse explain about
the combination of estrogen and progesterone in oral contraceptives?
a. Makes cervical mucus hostile to sperm
b. Prevents ovulation
c. Prohibits implantation of the egg
d. Acts as a barrier by destroying sperm
ANS: B
Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation.
DIF: Cognitive Level: Comprehension REF: Page 271
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. What should a woman expect after insertion of an intrauterine device (IUD)?
a. Menstrual flow will be lighter.
b. Menstrual cramps will be eliminated.
c. A string should be felt in the vagina.
d. The device should be changed every 2 years.
ANS: C
A woman should feel for the string periodically, especially after her period, to confirm the presence of the
IUD.
DIF: Cognitive Level: Comprehension REF: Page 273
TOP: IUDs KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. What information will the nurse provide when educating a woman about the correct use of a diaphragm?
a. Use of a spermicidal cream or jelly is not recommended.
b. Leave in place for at least 6 hours after intercourse.
c. Remove immediately after intercourse for douching.
d. It is effective for up to 48 hours if positioned properly.
ANS: B
To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in
place up to 24 hours.
DIF: Cognitive Level: Comprehension REF: Page 273
OBJ: 5 TOP: Diaphragm KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. The nurse is providing sexual education to a group of high school students. What will the nurse explain is
the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases?
a. Abstain from sex.
b. Use the male condom.
c. Use the female condom.
d. Use the barrier method.
ANS: A
Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.
DIF: Cognitive Level: Comprehension REF: Page 271
TOP: Abstinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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7. On day 13 of a 28-day cycle, a womans basal body temperature is 36.5 C (97.7 F). What will her
temperature measurement most likely be if ovulation takes place on day 14?
a. 35.9 C (96.7 F)
b. 36.3 C (97.3 F)
c. 36.7 C (98.1 F)
d. 37.1 C (98.9 F)
ANS: C
At the time of ovulation, body temperature will increase slightly, about 0.2 C (0.4 F).
DIF: Cognitive Level: Analysis REF: Page 270
TOP: Ovulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. The nurse tells a woman who is trying to conceive to check her cervical mucus for changes. What will she
expect the characteristic of cervical mucus to be a few days before ovulation?
a. Cloudy and tacky
b. Scant and thick
c. Thin and white
d. Clear and slippery
ANS: D
Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into
the cervix.
DIF: Cognitive Level: Knowledge REF: Page 270
TOP: Ovulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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9. The nurse is discussing cervical mucus changes with a woman who wishes to use natural family planning
methods. What information about cervical mucus at ovulation will the woman indicate to the nurse,
demonstrating that learning has taken place?
a. Cervical mucus enhances the motility of the sperm.
b. Cervical mucus indicates endometrial readiness for implantation.
c. Cervical mucus facilitates movement of the ovum through the fallopian tube.
d. Cervical mucus provides vaginal lubrication during intercourse.
ANS: A
Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.
DIF: Cognitive Level: Comprehension REF: Page 270
TOP: Cervical Mucus KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty
concentrating. What remedy might the nurse suggest to relieve these symptoms?
a. Drink tea or hot chocolate before going to bed.
b. Take a daily folic acid and vitamin C supplement.
c. Include complex carbohydrates and fiber in the diet.
d. Avoid exercise when symptoms occur.
ANS: C
A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic disorder.
DIF: Cognitive Level: Application REF: Page 263
TOP: Premenstrual Dysmorphic Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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11. The nurse explains that the drug clomiphene (Clomid) is used in infertility treatment. What is the primary
action of clomiphene (Clomid)?
a. Induces ovulation
b. Reduces endometriosis
c. Promotes implantation of a fertilized ovum
d. Inhibits excess prolactin secretion
ANS: A
Clomiphene (Clomid) induces ovulation. It may also increase sperm production, although this is an unlabeled
use.
DIF: Cognitive Level: Knowledge REF: Page 281
TOP: Clomid KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
12. At her regular gynecological examination, a woman tells the nurse that she is concerned about
osteoporosis. What suggestion can the nurse make to this patient?
a. Take a vitamin E supplement daily.
b. Do isometric exercises that can be practiced every day.
c. Include more dairy products and green, leafy vegetables in her diet.
d. Try to limit her intake of caffeine.
ANS: C
Foods rich in calcium include milk, dairy products, and green, leafy vegetables.
DIF: Cognitive Level: Application REF: Page 284
TOP: Prevention of Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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13. A 48-year-old woman tells the nurse, I missed my period last month. Am I in menopause? The nurse
knows that at which point is a woman considered to be menopausal?
a. Her periods have stopped for 1 year.
b. Her periods have been irregular and light for 12 months.
c. She has symptoms of vasomotor instability.
d. She experiences symptoms of decreased estrogen, such as dyspareunia.
ANS: A
When a womans menstrual periods have stopped for 1 year, she is considered menopausal.
DIF: Cognitive Level: Comprehension REF: Page 283
TOP: Menopause KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. The nurse is planning to teach a woman about perimenopause. What would the nurse include regarding
lowered estrogen level?
a. It prevent osteoporosis.
b. It decreases vaginal lubrication.
c. It raises the level of low-density lipoproteins.
d. It raises the level of high-density lipoproteins.
ANS: C
Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver
for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the
incidence of heart attacks and strokes.
DIF: Cognitive Level: Knowledge REF: Page 283
TOP: Menopause KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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15. What side effect would the nurse instruct a woman to look for when starting hormone replacement therapy
(HRT)?
a. Fatigue
b. Headache
c. Weight loss
d. Amenorrhea
ANS: B
Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes,
symptoms of thrombophlebitis, and cardiac symptoms.
DIF: Cognitive Level: Comprehension REF: Page 284
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. What will the nurse advise when a woman asks what she can do to reduce the discomfort of hot flashes?
a. Aerobic exercise helps control hot flashes.
b. Increase the amount of calcium and vitamin D in your diet.
c. Dress in layers of cotton clothing.
d. Drink plenty of fluids, particularly caffeinated beverages.
ANS: C
Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on
clothes when symptoms occur.
DIF: Cognitive Level: Application REF: Page 285
OBJ: 8 TOP: Prevention of Hot Flashes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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17. Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock
syndrome (TSS)?
a. Super-absorbency tampons are effective for overnight absorption.
b. Tampons should be changed at least every 4 hours.
c. Gloves should be worn when changing tampons.
d. TSS can be prevented by using a pad for the first 2 days of menstrual flow.
ANS: B
Tampons should be changed every 4 hours because a blood-soaked tampon is an excellent environment for
bacteria.
DIF: Cognitive Level: Comprehension REF: Page 264
TOP: TSS KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. What statement by a man considering a vasectomy indicates a need for further information?
a. Sterility does not occur immediately after the procedure.
b. We will need to use some form of birth control for about a month afterward.
c. The procedure involves the use of local anesthesia.
d. Ill need to remain in the hospital for a few days.
ANS: D
A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.
DIF: Cognitive Level: Analysis REF: Page 277
TOP: Vasectomy KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. At her 6-week postpartum checkup, a woman states, I am wondering about birth control. I used oral
contraceptives before, and Im breastfeeding noNw
nG
IT
usBe.CthOeMpill again? What is the nurses best response?
U.RCSaIN
a. You should know that oral contraceptives increase your milk production.
b. Oral contraceptives can be taken once lactation is well established.
c. You dont need to use any form of birth control as long as you are breastfeeding.
d. Oral contraceptives are contraindicated for the lactating woman.
ANS: B
Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established.
Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception until
that time.
DIF: Cognitive Level: Application REF: Page 272
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. A 17-year-old girl comes to the emergency department complaining of severe pain in her left lower
quadrant. An ovarian cyst is suspected. The nurse knows that what confirms this diagnosis?
a. Laparotomy
b. Oophorectomy
c. Transvaginal ultrasound
d. Hysteroscopy
ANS: C
Diagnosis of an ovarian cyst is made by transvaginal ultrasound.
DIF: Cognitive Level: Analysis REF: Page 287
TOP: Ovarian Cysts KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection.
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Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese
appearance. With what are these findings consistent?
a. Candidiasis
b. Trichomoniasis
c. Bacterial vaginosis
d. Chlamydia
ANS: A
The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese
appearance to the vaginal discharge.
DIF: Cognitive Level: Analysis REF: Page 266
OBJ: 4 TOP: Candidiasis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. The nurse is providing an informational session on oral contraceptives. Which of the following decrease
effectiveness of oral contraceptives?
a. Antihistamines for seasonal allergies
b. Iron preparations for treatment of anemia
c. Appetite suppressants for weight reduction
d. Anticonvulsants for treatment of epilepsy
ANS: D
Anticonvulsants decrease the effectiveness of oral contraceptives.
DIF: Cognitive Level: Comprehension REF: Page 272
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23. The nurse is instructing a man consideringNaUvRaSsIeN
ctGoT
mBy..CW
hat instruction will the nurse provide to address
OM
the postoperative time period?
a. Intercourse should be delayed for 6 weeks.
b. Sperm will still be ejaculated for a month.
c. Erections will be difficult to maintain.
d. Monthly sperm counts for a year will be necessary.
ANS: B
Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a month. A sperm
count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have
to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are not
affected by a vasectomy.
DIF: Cognitive Level: Comprehension REF: Page 277
TOP: Vasectomy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24. A woman diagnosed with endometriosis reports painful intercourse. What is the appropriate medical term
for the nurse to document when describing this symptom?
a. Dyspnea
b. Dysmenorrhea
c. Dyspareunia
d. Dysrhythmia
ANS: C
Dyspareunia is the term for painful sexual intercourse. Dyspnea is shortness of breath. Dysmenorrhea is
painful menstruation. Dysrhythmia is irregular heart rhythm.
DIF: Cognitive Level: Knowledge REF: Page 263
TOP: Dyspareunia KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. The nurse is educating a woman diagnosed with Premenstrual Dysphoric Disorder (PMDD). What is the
best type of diet for the nurse to recommend?
a. High protein, low fat
b. High carbohydrate, high fiber
c. Low calorie, low fat
d. Low carbohydrate, high protein
ANS: B
Treatment of PMDD includes a diet rich in complex carbohydrates and fiber (to lengthen effects of the
carbohydrate meal).
DIF: Cognitive Level: Application REF: Page 263
TOP: PMDD KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
26. The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all
that apply.)
a. Abdominal pain
b. Weight gain
c. Headache
d. Eye or visual problems
e. Speech disturbances
ANS: A, C, D, E
The memory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech
disturbances. Weight gain is an expected side N
efUfeRcSt IoNfGoTraBl.C
coOnM
traceptives.
DIF: Cognitive Level: Comprehension REF: Page 272
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
27. What are anonymous sperm donors screened for? (Select all that apply.)
a. Particular physical features
b. Genetic defects
c. Infections
d. High-risk behaviors
e. Nationality
ANS: B, C, D
Sperm donors are screened for genetic defects, infections, and high-risk behaviors. As an added precaution, the
sperm are kept frozen for 6 months before the sample is used.
DIF: Cognitive Level: Comprehension REF: Page 281
TOP: Sperm Donors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28. The nurse cautions that women with a history of which disorders are not candidates for HRT? (Select all
that apply.)
a. Melanoma
b. Estrogen-dependent breast cancer
c. Hepatitis C
d. Thromboembolic disease
e. Hyperthyroidism
ANS: A, B, C, D
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Persons who are absolutely restricted from HRT are those with melanoma, estrogen-dependent breast cancers,
chronic liver disorders, thromboembolic disease, and seizure disorders.
DIF: Cognitive Level: Comprehension REF: Page 284
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
29. The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten
worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (Select
all that apply.)
a. Antihypertensive drugs
b. Coffee
c. Alcohol
d. Diuretics
e. NSAIDs
ANS: A, B, C, D
Foods and drugs that increase the symptoms of urge incontinence are antidepressants, angiotensin converting
enzyme (ACE) inhibitors, caffeine, alcohol, and diuretics. NSAIDs do not increase incontinence.
DIF: Cognitive Level: Application REF: Page 287
TOP: Urge Incontinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
30. What might the nurse advise the woman with pelvic floor dysfunction to do for relief of the associated
discomfort? (Select all that apply.)
a. Lie down with feet elevated.
b. Practice Kegel exercises.
c. Assume knee-chest position periodically.
d. Perform leg lift exercises.
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e. Prevent constipation.
ANS: A, B, C, E
Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation
will reduce the pelvic discomfort of pelvic floor dysfunction.
DIF: Cognitive Level: Application REF: Page 286
TOP: Pelvic Floor Dysfunction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What information
will the nurse provide when educating this patient on alendronate (Fosamax)?
a. Drink 8 oz. of water following dosage.
b. Lay down for 30 minutes after taking.
c. This medication has no known side effects.
d. Avoid weight-bearing exercises.
ANS: A
Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of
alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30
minutes after taking the drug and before eating a meal. Weight-bearing exercises such as walking, hiking, stair
climbing, and dancing are advisable. High-impact exercises should be avoided.
DIF: Cognitive Level: Comprehension REF: Page 284
TOP: Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
32. The nurse is caring for a patient planning to undergo a uterine fibroid embolization. What information can
the nurse provide? (Select all that apply.)
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a. It involves laser destruction of fibroids.
b. It has fewer physiological effects than drug therapy.
c. It is nonsurgical.
d. It is associated with more psychological effects than surgery.
e. It has a faster recovery time than surgery.
ANS: B, C, E
Uterine fibroid embolization is a nonsurgical technique of treating uterine fibroids that involves fewer
physiological effects than drug therapy, fewer psychological effects than surgery, and a faster recovery time
than surgery. Myolysis is the laser or electrosurgical destruction of fibroids, and it also preserves fertility.
DIF: Cognitive Level: Comprehension REF: Page 287
TOP: Uterine Fibroid KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
COMPLETION
33. The nurse outlines the process of ova being mixed with sperm and then the resulting embryos being
returned to the mothers uterus. This process of infertility treatment is
.
ANS:
in vitro fertilization
The in vitro fertilization technique mixes ova with sperm and deposits several of the resulting embryos in the
mothers uterus.
DIF: Cognitive Level: Knowledge REF: Page 282
OBJ: 6 TOP: In Vitro Fertilization
KEY: Nursing Process Step: Implementation NURSINGTB.COM
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
34. When intraabdominal pressure increases from laughing or sneezing in a woman with a cystocele,
results.
ANS:
stress incontinence
When intraabdominal pressure increases, such as with laughing, coughing, or sneezing, a woman with a
cystocele is said to have stress incontinence.
DIF: Cognitive Level: Knowledge REF: Page 286
TOP: Cystocele KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35.
is the presence of tissue that resembles endometrium outside the uterus.
ANS:
Endometriosis
Endometriosis is the presence of tissue that resembles endometrium outside the uterus.
DIF: Cognitive Level: Knowledge REF: Page 263
TOP: Endometriosis KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 12: The Term Newborn
MULTIPLE CHOICE
1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture
line. How would the nurse refer to this finding when documenting?
a. Molding
b. Caput succedaneum
c. Cephalohematoma
d. Enlarged fontanelle
ANS: C
A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not
cross the suture line.
DIF: Cognitive Level: Comprehension REF: Page 286
TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old
infant?
a. Molding doesnt cause any problems. Dont worry about it.
b. Did you deliver vaginally or by cesarean section?
c. The babys head conformed to the shape of the birth canal. It will go away soon.
d. A traumatic delivery can cause molding.
ANS: C
The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform
to the size and shape of the birth canal.
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DIF: Cognitive Level: Application REF: Page 286
TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What symptom assessed in the newborn shortly after delivery should be reported?
a. Cyanosis of the hands and feet
b. Irregular heart rate
c. Mucus draining from the nose
d. Sternal or chest retractions
ANS: D
Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.
DIF: Cognitive Level: Analysis REF: Page 292
TOP: Newborn AssessmentRespiratory
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out,
and then both came back toward the midline. How would the nurse interpret this behavior?
a. The Moro reflex
b. The grasp reflex
c. An abnormality of the musculoskeletal system
d. A neurological abnormality
ANS: A
The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by
drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.
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DIF: Cognitive Level: Analysis REF: Page 285
OBJ: 2 TOP: Newborn Reflexes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal
reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
a. Sucking
b. Rooting
c. Grasping
d. Tonic neck
ANS: B
The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in
anticipation of food.
DIF: Cognitive Level: Application REF: Page 285
OBJ: 2 TOP: Newborn Reflexes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
a. Depressed and sunken
b. Triangular shaped
c. Smaller than the posterior fontanelle
d. Open and diamond shaped
ANS: D
The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones.
It should not be raised or sunken, and it closesNbUeR
twSeIN
enG1T2Ba.CnO
dM
18 months of age.
DIF: Cognitive Level: Comprehension REF: Page 286
OBJ: 3 TOP: Newborn AssessmentHead
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What statement indicates the parent understands the guidelines for bathing a newborn?
a. Ill use a mild soap to clean all of the body parts.
b. I am going to add bath oil to the water to keep the babys skin soft.
c. I should shampoo the head after washing the rest of the body.
d. Ill wash from the feet upward and change the washcloth for the face.
ANS: C
The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.
DIF: Cognitive Level: Comprehension REF: Page 298
OBJ: 8 TOP: Home CareBathing the Infant
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal?
a. An axillary temperature of 36.6 C (98 F)
b. An apical pulse rate of 178 beats/min
c. Respirations of 35 breaths/min
d. Blood pressure of 80/50 mm Hg
ANS: B
The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should
be reported.
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DIF: Cognitive Level: Comprehension REF: Page 293
TOP: Newborn AssessmentVital Signs
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2
days after birth?
a. Yellow
b. Brown
c. Greenish brown
d. Black and tarry
ANS: A
The stool of a breastfed infant is bright yellow, soft, and pasty.
DIF: Cognitive Level: Application REF: Page 302
OBJ: 8 TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains
when she has a bowel movement. What is nurses most helpful response?
a. Give the baby one serving of fruit per day.
b. Increase the amount and frequency of her feedings.
c. It sounds like the baby is uncomfortable because she is constipated.
d. Newborns might strain with bowel movements because their muscles arent fully developed.
ANS: D
Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No
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treatment is required.
DIF: Cognitive Level: Application REF: Page 303
TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in
grams 3 days later?
a. 2900
b. 3100
c. 3300
d. 3800
ANS: C
In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.
DIF: Cognitive Level: Analysis REF: Page 294
OBJ: 3 TOP: Newborn AssessmentWeight
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be
bloody mucus. What does the nurse explain as the cause?
a. Premature stimulation of the ovarian hormones by the pituitary system
b. Cessation of female sex hormones transferred in utero from mother to infant
c. The increased amount of circulating blood from the mother throughout pregnancy
d. Trauma to the genitalia during the birth process
ANS: B
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109
Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.
DIF: Cognitive Level: Comprehension REF: Page 296
TOP: Newborn AssessmentGenitourinary
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most
appropriate nursing response to this mother?
a. Tell me how many hours per day your baby sleeps.
b. It is normal for newborns to sleep most of the day.
c. Newborns generally sleep 12 to 15 hours per day.
d. You will find as the baby gets older, he sleeps less.
ANS: A
Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the
mother means by too much before giving any information.
DIF: Cognitive Level: Application REF: Page 290
TOP: Discharge Planning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
a. Infant refuses a feeding
b. Infant has an axillary temperature of 97 F
c. Infant has three pasty, yellow-brown stools in 24 hours
d. Infants diaper is not wet after 8 hours
ANS: D
Decreased or lack of voiding by the newborn sNhUoR
ulSdIN
beGrTeBp.oCrO
teM
d to the pediatrician or nurse practitioner to
prevent dehydration.
DIF: Cognitive Level: Comprehension REF: Page 295
TOP: Discharge Planning KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. On what knowledge would the nurse base a response to a mother who questions, Do you think my baby
recognizes my voice?
a. Voice recognition is delayed because the ears are not well developed at birth.
b. Infants respond to voice by increasing movements and sucking.
c. Infants initially respond to low-pitched voices.
d. Neonates can distinguish a mothers voice from other sounds in the first days of life.
ANS: D
The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days
of life.
DIF: Cognitive Level: Knowledge REF: Page 286
OBJ: 8 TOP: Newborn AssessmentHearing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had
lost weight. What is the most appropriate intervention by the nurse?
a. Do nothing because this is a normal occurrence.
b. Report the discrepancy to the pediatrician immediately.
c. Decrease the interval between the infants feedings.
d. Try feeding the infant a different type of formula.
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ANS: A
It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No
change in the plan of care is needed.
DIF: Cognitive Level: Application REF: Page 294
OBJ: 3 TOP: Newborn AssessmentWeight
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. Parents express concern about the milia on the face and nose of their infant. What is the nurses most
helpful response when instructing the parents?
a. Contact a pediatric dermatologist for topical medication.
b. Squeeze out the white material after cleansing the face.
c. Wash the infants face with a mild astringent several times a day.
d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.
ANS: D
Milia require no treatment. This skin manifestation will disappear spontaneously.
DIF: Cognitive Level: Application REF: Page 297
OBJ: 5 TOP: Newborn AssessmentSkin
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the
nurses first action?
a. Place the tip in the nose and squeeze the bulb gently.
b. Suction secretions from the nose before the mouth.
c. Depress the bulb before inserting the syringe tip into the mouth.
d. Insert the tip into the back of the mouth to rN
eaUcRhSm
cuTsB. .COM
INuG
ANS: C
The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly
released, creating the suction.
DIF: Cognitive Level: Application REF: Page 291
OBJ: 3 TOP: Newborn AssessmentRespiratory
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19. The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin.
Which finding needs to be reported promptly to the childs pediatrician?
a. The hands and feet feel cooler than the rest of the body.
b. Skin is peeling on several parts of the infants body.
c. There is a small pink patch on the left eyelid and one on the neck.
d. Today, the infants skin has a yellowish tinge.
ANS: D
Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week.
Evidence of jaundice is reported and the newborn is evaluated.
DIF: Cognitive Level: Analysis REF: Page 297
TOP: Newborn AssessmentSkin (Jaundice)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. What action does the nurse implement to protect newborns from infection while in the nursery?
a. Keep the newborn dressed warmly.
b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F).
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c. Wash hands before touching each infant.
d. Wear a disposable gown when giving infant care.
ANS: C
Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands
between handling different babies.
DIF: Cognitive Level: Application REF: Page 303
TOP: Preventing Infection KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
21. Which assessment of the newborn should be reported?
a. Head circumference is 5 cm greater than the chest circumference
b. Hands and feet are warm with a blue color
c. Temperature is 36.6 C (97.8 F)
d. Head has a longer than normal shape to it
ANS: A
The circumference of the head should be less than 2 cm greater than that of the chest. All other listed
assessments are within the norm.
DIF: Cognitive Level: Analysis REF: Page 288
OBJ: 3 TOP: Newborn Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse
explain this transitory skin discoloration is called?
a. Epsteins pearls
b. Milia
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c. Stork bites
d. Mongolian spots
ANS: D
Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.
DIF: Cognitive Level: Comprehension REF: Page 297
TOP: Mongolian Spots KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should
be brought to the physicians attention first?
a. White blood cell count of 18,000
b. Hemoglobin of 18.5
c. Hematocrit of 56
d. Bilirubin of 15
ANS: D
A bilirubin of 15 is elevated and requires further immediate investigation.
DIF: Cognitive Level: Analysis REF: Page 297
OBJ: 3 TOP: Labwork KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
24. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.)
a. Reflexes
b. Color
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c. Heart rate
d. Respiration
e. Weight
ANS: A, B, C, D
The Apgar score is a standardized method of evaluating the newborns condition immediately after delivery.
Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is
obtained 1 minute after birth and again after 5 minutes.
DIF: Cognitive Level: Application REF: Page 292
TOP: Apgar Score KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
25. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.)
a. Swaddling
b. Rocking
c. Offering a pacifier
d. Distraction
e. Cuddling
ANS: A, B, C, E
Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain
remedies. Distraction is not a dependable method of pain reduction with infants.
DIF: Cognitive Level: Comprehension REF: Page 291
TOP: Noninvasive Pain Relief KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
26. The nurse reminds new parents that newborns must be protected from environments that are too cold or too
hot because of which aspects of the newbornsNpU
hyRsSioIN
loGgTyB
? .(CSO
elM
ect all that apply.)
a. Very little subcutaneous fat
b. Low metabolic rates
c. Ineffective sweat glands
d. Small fluid reserves
e. Low red blood cell counts
ANS: A, C
Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have
ineffective sweat glands and cannot cool themselves through evaporation.
DIF: Cognitive Level: Comprehension REF: Page 293
TOP: Environmental Thermal Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that
apply.)
a. Wash penis with warm water.
b. Wipe with alcohol swab.
c. Gently remove the yellow crust formation.
d. Apply diaper loosely.
e. Dress with simple bandage.
ANS: A, D
Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in
place, and diapering loosely.
DIF: Cognitive Level: Application REF: Page 296
OBJ: 7 TOP: Circumcision Care
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
28. The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.)
a. Blinking
b. Sneezing
c. Gagging
d. Sucking
e. Grasping
ANS: A, B, C, D, E
All listed reflexes are present in the full-term newborn.
DIF: Cognitive Level: Knowledge REF: Page 285
OBJ: 2 TOP: Reflexes KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29. The nurse takes into consideration that newborns are especially prone to dehydration because of which
aspects of their physiology? (Select all that apply.)
a. Small glomeruli
b. Minimal renal blood flow
c. Inactive gastrointestinal (GI) tract
d. Excessive fluid loss from the sweat glands
e. Immature renal tubules that do not concentrate urine
ANS: A, B, E
The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are
unable to effectively concentrate urine. The GI tract is active. The infants sweat glands do not work effectively
and allow very little fluid loss through sweat.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS2I9N5GTB.COM
TOP: Dehydration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Growth and Development
COMPLETION
30. The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to
assessment.
ANS:
pain
CRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for infants.
DIF: Cognitive Level: Comprehension REF: Page 290
OBJ: 3 TOP: Pain Assessment Guides
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31. The nurse advises the nursing mother that the immune globulin that is found in breast milk is
.
ANS:
IgA
IgA is an immune globulin that is found in breast milk.
DIF: Cognitive Level: Knowledge REF: Page 303
TOP: IgA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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32. The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow
color, this is normal
stool.
ANS:
transition
The transitional stool has lost its dark green meconium color and gradually changes to a loose greenish-yellow
stool with mucus.
DIF: Cognitive Level: Comprehension REF: Page 302
OBJ: 8 TOP: IgA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33. Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the
.
ANS:
dancing reflex
Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the
dancing reflex.
DIF: Cognitive Level: Knowledge REF: Page 286
TOP: Reflexes KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
34. Place the newborn phases of the sleep-wake states in proper order from first to last. Put a comma and space
between each answer choice (a, b, c, d, etc.)
a. Stability phase
b. First reactive phase
c. Sleep phase
d. Second reactive phase
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ANS:
B, C, D, A
At birth the newborn passes through the phases of sleep-wake states as part of the adjustment to life outside of
the uterus: first reactive phase, sleep phase, second reactive phase, stability phase.
DIF: Cognitive Level: Comprehension REF: Page 290
TOP: Sleep KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. Put the steps of nasal bulb suctioning for the newborn in the correct order from first to last. Put a comma
and space between each answer choice (a, b, c, d, etc.)
a. Clean bulb syringe.
b. Release pressure.
c. Insert narrow portion into nose.
d. Compress ball of bulb syringe.
e. Remove and empty into receptacle.
ANS:
D, C, B, E, A
First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose. The
pressure is released, and the syringe is removed and emptied into the receptacle. The bulb syringe is cleaned
and stored at the end of the procedure.
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DIF: Cognitive Level: Application REF: Page 291
OBJ: 8 TOP: Bulb Syringe Suctioning
KEY: Nursing Process Step: Implementation
MSC: Safety and Infection Control: Safe Use of Equipment
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Chapter 13: Preterm and Postterm Newborns
MULTIPLE CHOICE
1. The nurse is assessing a preterm infant. To what does the infants level of maturation refer?
a. Actual time the fetus remained in the uterus
b. Age on the Dubowitz scoring system
c. Infants weight as compared to the gestational age
d. Ability of the organs to function outside of the uterus
ANS: D
Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function
outside of the uterus.
DIF: Cognitive Level: Knowledge REF: Page 312
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at
risk for what?
a. Skin breakdown
b. Renal failure
c. Brain damage
d. Heart failure
ANS: C
The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.
DIF: Cognitive Level: Comprehension REF: Page 319
TOP: Jaundice KEY: Nursing Process Step: DNaU
taRCSoIN
lleGcTtiBo.nCOM
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first
few days of life?
a. Weak or absent sucking or swallowing reflex
b. Inability to digest food properly
c. Refusal to take formula by mouth
d. Need for a larger quantity of formula at each feeding
ANS: A
When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to
promote nutrition.
DIF: Cognitive Level: Comprehension REF: Page 320
TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. What deficiency causes a preterm infant respiratory distress syndrome?
a. Protein
b. Estrogen
c. Hyaline
d. Surfactant
ANS: D
The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm
infant.
DIF: Cognitive Level: Knowledge REF: Page 314
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
a. Check tube placement by injecting air into the stomach.
b. Weigh the infant before the feeding.
c. Aspirate stomach contents.
d. Check serum glucose level.
ANS: C
When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is
started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the
amount of feeding in the stomach.
DIF: Cognitive Level: Application REF: Page 320
TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal
lung maturity?
a. Prostaglandins
b. Oxytocin
c. Magnesium sulfate
d. Corticosteroids
ANS: D
Surfactant production can be increased by administering corticosteroids to the mother before delivery.
DIF: Cognitive Level: Comprehension REF: Page 315
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
Bt.C
7. The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate
nursing action in this situation?
a. Administer oxygen via a nasal cannula.
b. Gently rub the infants feet or back.
c. Ventilate with an Ambu bag.
d. Perform nasopharyngeal suctioning.
ANS: B
Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe.
DIF: Cognitive Level: Application REF: Page 315
TOP: Preterm InfantApnea KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium
gluconate?
a. Seizures
b. Bradycardia
c. Dysrhythmias
d. Tetany
ANS: B
The infant receiving intravenous calcium gluconate should be monitored for bradycardia.
DIF: Cognitive Level: Application REF: Page 317
TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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9. What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator?
a. The infant has a small body surface-to-weight ratio.
b. Heat increases the flow of oxygen to the extremities.
c. The infants temperature control mechanism is immature.
d. Heat within the incubator facilitates drainage of mucus.
ANS: C
The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in
the brain is immature.
DIF: Cognitive Level: Comprehension REF: Page 317
TOP: Thermoregulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen
therapy?
a. Monitor arterial oxygen levels with a pulse oximeter.
b. Position the head slightly lower than the body.
c. Administer low concentrations of oxygen.
d. Keep the infants eyes covered at all times.
ANS: A
Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority
in the neonatal intensive care unit (NICU).
DIF: Cognitive Level: Application REF: Page 318
TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. When assessing a preterm infant, the nurseNoUbRsS
erIvNeGsTnBas.CalOfM
laring, sternal retractions, and expiratory
grunting. What do these findings indicate?
a. Respiratory distress syndrome
b. Postmaturity syndrome
c. Apneic episode
d. Cold stress
ANS: A
Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by
the infant are indicative of respiratory distress.
DIF: Cognitive Level: Analysis REF: Page 313
OBJ: 4 TOP: Respiratory Distress Syndrome
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a
bloody stool?
a. Assess for abdominal distention.
b. Decrease the amount of the next feeding.
c. Institute enteric precautions.
d. Get a culture of the next stool.
ANS: A
Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis.
Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.
DIF: Cognitive Level: Application REF: Page 320
TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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13. Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What
will the nurse teaching about stimulating the infant tell the parents?
a. To bring in colorful pictures and toys to place in the incubator
b. That stimulating the infant during feedings increases intake
c. To stroke the infant during feeding to increase intake
d. Not to disturb the infant between feedings
ANS: C
During gavage feedings, stroking the infant gently can provide stimulation.
DIF: Cognitive Level: Application REF: Page 320
TOP: Family Reaction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is
aware that these symptoms indicate what?
a. Respiratory distress syndrome
b. Hypoglycemia
c. Necrotizing enterocolitis
d. Renal failure
ANS: B
The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infants glycogen stores
are not adequate.
DIF: Cognitive Level: Analysis REF: Page 317
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. The mother of a 4-month-old infant, born N
prUem
urGelTyB, .aCsO
ksMthe nurse if her daughter will always be small
RSaItN
for her age. What is the most appropriate nursing response?
a. Preterm infants usually remain smaller than term infants throughout childhood.
b. Your daughter will be the same size as other children by the time she is 1 year old.
c. Prematurity is associated with short stature but does not affect weight gain.
d. It takes about two years for the preterm infant to catch up to a full-term infant.
ANS: D
In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of
the term infant by about the second year.
DIF: Cognitive Level: Application REF: Page 323
TOP: Preterm Infant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the
optimum output for this infant?
a. 1 to 3 mL/kg/hr
b. 4 to 6 mL/kg/hr
c. 7 to 9 mL/kg/hr
d. 10 to 14 mL/kg/hr
ANS: A
The optimum output for a preterm infant is 1 to 3 mL/kg/hr.
DIF: Cognitive Level: Comprehension REF: Page 319
TOP: Immature Kidneys KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17. The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the
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nurse expect this infant to exhibit?
a. Thin, long extremities
b. Large genitals for its size
c. Minimal vernix caseosa
d. Loose, transparent skin
ANS: D
The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of
the preterm infant is skin that is loose and transparent.
DIF: Cognitive Level: Comprehension REF: Page 312
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse in a pediatricians office is preparing to do a developmental assessment on a 3-month-old infant
who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement
to adjust for the preterm birth?
a. 1
b. 2
c. 3
d. 4
ANS: B
The growth and development of a preterm infant are based on the current age minus the number of weeks
before term that the infant was born.
DIF: Cognitive Level: Analysis REF: Page 323
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
NURSINGTB.COM
19. The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the
nurses most appropriate response?
a. The placenta does not function adequately as it ages.
b. Infants born postmaturely are generally large.
c. Delivery of the postterm infant is more difficult.
d. There is less amniotic fluid.
ANS: A
Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with
maturity.
DIF: Cognitive Level: Comprehension REF: Page 324
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. What symptoms of cold stress might the nurse recognize in a preterm infant?
a. Tremors and weak cry
b. Plasma glucose level below 40 mg/dL
c. Warm skin with low core temperature
d. Increased respiratory rate and periods of apnea
ANS: D
Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature,
bradycardia, mottling of skin, and lethargy.
DIF: Cognitive Level: Comprehension REF: Page 317
OBJ: 5 TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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21. The nurse is caring for an infant born at 43 weeks. What would the physical assessment reveal?
a. Dry, peeling skin
b. Minimal hair on the head
c. Short, rough nails
d. Abundant lanugo on the body
ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling.
DIF: Cognitive Level: Comprehension REF: Page 324
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. What term describes the age of a neonate that is based on the actual time in utero?
a. Maturational age
b. Gestational age
c. Neurological age
d. Chronological age
ANS: B
The gestational age is the age based on the actual time in the uterus.
DIF: Cognitive Level: Knowledge REF: Page 312
TOP: Gestational Age KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Growth and Development
23. How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and
the incubator?
a. Every hour
b. Every 2 hours
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c. Every 4 hours
d. Every 8 hours
ANS: B DIF: Cognitive Level: Comprehension REF: Page 317
OBJ: 5 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24. Why is the postterm neonate at risk for cold stress?
a. Inadequate vernix caseosa
b. Hypoxia from a deteriorated placenta
c. Polycythemia
d. Fat stores have been used in utero for nourishment
ANS: D
Fat stores have been used in utero for nourishment during the extended pregnancy.
DIF: Cognitive Level: Comprehension REF: Page 324
TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10
ounces. What will the nurse consider this newborn?
a. Term
b. Small for gestational age
c. Large for gestational age
d. Late preterm
ANS: C
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Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant
this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42
weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.
DIF: Cognitive Level: Analysis REF: Page 311
OBJ: 1 TOP: Gestational Age
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress
syndrome (RDS). When will the nurse anticipate seeing improvement of lung function?
a. Immediately
b. Within 3 days
c. 1 to 2 weeks
d. At least 1 month
ANS: B
In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur,
with improvement of lung function seen within 72 hours.
DIF: Cognitive Level: Comprehension REF: Page 315
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
27. The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.)
a. Seizures
b. Asphyxia
c. Paralysis
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d. Visual defects
e. Polycythemia
ANS: A, B, E
The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.
DIF: Cognitive Level: Comprehension REF: Page 324
TOP: Potential Problems of the Postterm Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are
possible causes of preterm delivery? (Select all that apply.)
a. Placenta previa
b. Gestational diabetes
c. Pregnancy-induced hypertension
d. Hyperemesis gravidarum
e. Chloasma
ANS: A, B, C
The predisposing causes of preterm birth are numerous; in many instances the cause is unknown. Prematurity
may be caused by multiple births, illness of the mother (e.g., malnutrition, heart disease, diabetes mellitus, or
infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental
abnormalities that may result in premature rupture of the membranes, placenta previa (in which the placenta
lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also
indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of
cocaine and other drugs. Hyperemesis gravidarum and chloasma are not risk factors for preterm birth.
DIF: Cognitive Level: Comprehension REF: Page 312
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TOP: Preterm Birth KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
29. The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select
all that apply.)
a. Paleness
b. Transparent skin
c. Superficial scalp veins
d. Vomiting
e. Bulging fontanelles
ANS: A, D, E
Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent
skin and superficial scalp veins are expected findings.
DIF: Cognitive Level: Application REF: Page 322
OBJ: 4 TOP: Potential Problems of the Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
30. The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of
weeks.
ANS:
34
Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.
DIF: Cognitive Level: Knowledge REF: Page 315
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TOP: Surfactant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The nurse providing stimulation to a preterm infant should schedule stimulation not to conflict with
.
ANS:
feeding
Preterm babies should not be stimulated during feeding so they can focus on sucking and swallowing.
DIF: Cognitive Level: Application REF: Page 323
TOP: Stimulation and Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
32. Assessment of altered skin integrity in the preterm infant is made difficult because of the immature
immune system that cannot produce a(n)
reaction.
ANS:
inflammatory
The immature immune system cannot produce an inflammatory reaction to show redness or swelling. Without
such symptoms, skin integrity is more difficult to assess in the preterm infant.
DIF: Cognitive Level: Comprehension REF: Page 321
OBJ: 4 TOP: Skin Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. The nurse encourages the anxious mother of a preterm infant to consider the warming technique of holding
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the infant between her breasts with skin-to-skin contact under a blanket. This technique is the
method.
care
ANS:
kangaroo
The kangaroo care method is when the mother places the infant between her breasts for skin-to-skin contact,
and then both mother and infant are wrapped in a blanket as a warming technique. This method also facilitates
maternal-infant bonding.
DIF: Cognitive Level: Knowledge REF: Page 320
TOP: Kangaroo Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34. The nurse is aware that the preterm infant has an increased tendency to bleed due to deficient levels of
.
ANS:
prothrombin
Preterm infants have deficient levels of prothrombin, which increases the tendency to bleed spontaneously.
DIF: Cognitive Level: Knowledge REF: Page 318
TOP: Bleeding Tendency KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
35. The nurse explains that the
a neonate based on appearance and neuromuscular criteria.
ANS:
Ballard Score
is a tool used to determine the gestational age of
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The Ballard Score is a standardized method to determine gestational age based on external characteristics and
neurological development.
DIF: Cognitive Level: Knowledge REF: Page 313
OBJ: 1 TOP: Ballard Scoring System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36. Bronchopulmonary dysplasia is the toxic response of the lung to
therapy.
ANS:
oxygen
Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy.
DIF: Cognitive Level: Knowledge REF: Page 315
TOP: Bronchopulmonary Dysplasia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 14: The Newborn with a Perinatal Injury or Congenital
Malformation
MULTIPLE CHOICE
1. What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of
cerebrospinal fluid?
a. Meningitis
b. Meningocele
c. Spina bifida occulta
d. Hydrocephalus
ANS: D
Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.
DIF: Cognitive Level: Knowledge REF: Page 329
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to
implement?
a. Align the limbs.
b. Support the head.
c. Keep the head lower than the hip.
d. Check intake and output.
ANS: B
The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be
supported when feeding and moving the childNtoUpRrSeIvNeG
ntTiBn.jC
urOyMto the neck.
DIF: Cognitive Level: Application REF: Page 331
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal
shunt. How should the nurse position this infant?
a. Prone, with the head of the bed elevated
b. Supine, with the head flat
c. Side-lying on the operative side
d. In a semi-Fowlers position
ANS: D
If the fontanelles are bulging, the child will be positioned in a semi-Fowlers position to promote drainage from
the ventricles through the shunt.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 4 TOP: Hydrocephalus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What nursing action will the nurse implement after feeding an infant with hydrocephalus?
a. Position the infant sitting upright in an infant seat.
b. Place the infant over the shoulder to burp.
c. Leave the infant in a side-lying position.
d. Stimulate the infant by rubbing its feet.
ANS: C
Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-
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lying position in a quiet atmosphere to reduce the incidence of vomiting.
DIF: Cognitive Level: Application REF: Page 331
TOP: Feeding a Hydrocephalic Child KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the
priority preoperative nursing care of this newborn?
a. Keep the sac dry.
b. Diaper snugly.
c. Position prone in an incubator.
d. Move from side to side every hour.
ANS: C
The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The
infants hips are kept lower than the lesion, and the infant is usually not in diapers.
DIF: Cognitive Level: Analysis REF: Page 333
TOP: Myelodysplasia and Spina Bifida KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and
observes an increasing abdominal girth. What is the most appropriate response?
a. Elevate the childs head.
b. Check bowel sounds.
c. Record retention of feeding.
d. Notify the charge nurse of possible malabsorption.
ANS: D
An increasing abdominal girth in a child with N
aU
VRPSsIhNuGnTt B
m.C
ayObMe indicative of malabsorption of the
cerebrospinal fluid (CSF) that is being shunted to the peritoneum.
DIF: Cognitive Level: Application REF: Page 331
OBJ: 6 TOP: VP Shunt KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the
parents to report immediately?
a. Facial paralysis
b. Ear infections
c. Increasing intracranial pressure (ICP)
d. Drooling
ANS: B
Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take
the child to the health care provider at the first sign of earache.
DIF: Cognitive Level: Application REF: Page 336
TOP: Complication of Cleft Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include:
a. Feeding the infant with a spoon to avoid sucking
b. Positioning the infant on the abdomen to facilitate drainage
c. Applying elbow restraints to protect the surgical area
d. Providing minimal stimulation to prevent injury to the incision
ANS: C
Elbow restraints are used postoperatively to prevent the infant from damaging the operative area.
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DIF: Cognitive Level: Application REF: Page 336
TOP: Cleft Lip and Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9. Which statement indicates that parents understand how to feed their infant who had a surgical repair for a
cleft lip?
a. We are feeding the baby with a dropper for 2 weeks.
b. We resumed bottle feeding after discharge.
c. We started the baby on solid food yesterday.
d. The baby is drinking well from a straw.
ANS: A
The infant is fed with a dropper until the incision is completely healed, about 1 to 2 weeks after surgery.
DIF: Cognitive Level: Application REF: Page 336
TOP: Cleft Lip and Palate KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10. An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What
nursing action is the most appropriate?
a. Feed solid foods with the spoon at the side of the mouth.
b. Puree foods and offer them through a straw.
c. Place small bites of food in the mouth with a tongue blade.
d. Offer small, frequent meals of finger foods.
ANS: A
The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only
the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of
the mouth.
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DIF: Cognitive Level: Application REF: Page 336
TOP: Cleft Lip and Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11. When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
a. Hypotonicity of the leg muscles
b. One leg is shorter than the other
c. Broadening and flattening of the buttocks
d. Two skinfolds on the back of each thigh
ANS: B
When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on
the unaffected side.
DIF: Cognitive Level: Comprehension REF: Page 338
OBJ: 8 TOP: Developmental Hip Dysplasia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse knows that what is the
usual treatment for an infant with this diagnosis?
a. A Pavlik harness
b. A body spica cast
c. Traction
d. Triple-diapering
ANS: A
In infants who are more than 2 months of age, longer-term immobilization with a Pavlik harness is required.
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DIF: Cognitive Level: Comprehension REF: Page 338
OBJ: 8 TOP: Developmental Hip Dysplasia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that what is the
optimal time for testing for phenylketonuria?
a. In the first 24 hours of life
b. After 2 to 3 days
c. At 4 to 6 weeks of age
d. At 2 months of age
ANS: B
Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had
enough time to ingest protein through feedings, and the chance of false-negative results will be reduced.
DIF: Cognitive Level: Comprehension REF: Page 341
TOP: PKU KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet
should the nurse suggest?
a. Lifelong high-protein diet
b. A formula that is low in the amino acid leucine
c. A soy-based formula
d. Substitute Lofenalac for some protein foods
ANS: D
A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted
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for natural protein foods.
DIF: Cognitive Level: Comprehension REF: Page 341
TOP: PKU KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
15. Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric clinic. What
should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?
a. Preventing hyperthermia
b. Respiratory care
c. Prevention of diarrhea
d. Incontinence care
ANS: B
The child with Down syndrome has generalized hypotonicity, which caused mucus accumulation and
respiratory problems.
DIF: Cognitive Level: Application REF: Page 343
OBJ: 10 TOP: Down Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16. What would the nurse include when instructing parents about positioning their toddler who has just had a
body spica cast applied?
a. Prop the child upright with pillows for meals.
b. Use the bar between the legs to turn the child.
c. Put the child on her abdomen to sleep.
d. Change the childs position frequently.
ANS: D
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The childs position must be changed frequently to relieve pressure and promote circulation.
DIF: Cognitive Level: Application REF: Page 339
TOP: Developmental Hip Dysplasia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
17. The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to
administer RhoGAM to this patient?
a. She has had one Rh-negative child and is pregnant with an Rh-negative child.
b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus.
c. She has had an O-negative child and is pregnant with a B-negative child.
d. She is a primipara with an O-negative child.
ANS: B
The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rh
positive child and is now pregnant with another.
DIF: Cognitive Level: Analysis REF: Page 344
TOP: Rh Concerns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurses best
response?
a. The light increases the infants metabolism.
b. The light stimulates liver function.
c. The light dilates blood vessels.
d. The light breaks down bilirubin.
ANS: D
Severe jaundice can cause kernicterus, an accuNm
oG
n ToB
f b.CilOirM
ubin in the brain tissue, which can lead to
UuRlaStIiN
serious brain damage. The light breaks down excess bilirubin so that it can be excreted.
DIF: Cognitive Level: Application REF: Page 346
TOP: Hemolytic Disease of the Newborn
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse
explains that a child with a cleft lip usually undergoes surgical repair at which time?
a. Immediately after birth
b. By 3 months of age
c. After 12 months of age
d. Varies in every case
ANS: B
A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.
DIF: Cognitive Level: Comprehension REF: Page 335
TOP: Cleft Lip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having
phototherapy?
a. Cover the infants head with a hat.
b. Dress the infant lightly in a T-shirt.
c. Keep the infants eyes covered.
d. Reposition the infant at least every 4 to 8 hours.
ANS: C
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The infants eyes are protected with patches to prevent damage from the high-intensity lights.
DIF: Cognitive Level: Application
REF: Page 346
OBJ: 12 TOP: Phototherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess
for with this neonate?
a. Hypoglycemia
b. Erythroblastosis fetalis
c. Intracranial hemorrhage
d. Pancreatic failure
ANS: A
The newborn of a mother with diabetes is prone to hypoglycemia.
DIF: Cognitive Level: Application REF: Page 351
TOP: Infant of a Diabetic Mother KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
22. What assessment made by the nurse would lead the nurse to suspect hip dysplasia?
a. Asymmetrical gluteal folds
b. Limited adduction of the affected side
c. Foot turned inward
d. Deep inguinal creases
ANS: A
The gluteal folds are asymmetrical because thN
eU
heRaSdIN
ofGtThB
e .fCeO
mM
ur has slipped out of the acetabulum. There is
also limited abduction of the affected side, and when the legs are flexed the affected leg seems to be shorter.
DIF: Cognitive Level: Comprehension REF: Page 337
OBJ: 8 TOP: Hip Dysplasia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
23. The nurse is providing care to a child with Down syndrome. What body system has the highest risk of
congenital anomaly in a child with Down syndrome?
a. Reproductive system
b. Genitourinary system
c. Cardiovascular system
d. Gastrointestinal system
ANS: C
Down syndrome children are prone to deformities of the cardiovascular system.
DIF: Cognitive Level: Knowledge REF: Page 343
TOP: Down Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24. The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the
most appropriate response?
a. Cystic fibrosis is a chromosomal defect.
b. Cystic fibrosis is a metabolic defect.
c. Cystic fibrosis is a malformation present at birth.
d. Cystic fibrosis is a blood disorder.
ANS: B
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Inborn errors of metabolism include a number of inherited diseases that affect body chemistry. There may be
an absence or a deficiency of a substance necessary for cell metabolism. The deficient substance is usually an
enzyme. Almost any organ of the body may be damaged. Examples of inborn errors of metabolism include
cystic fibrosis and phenylketonuria (PKU). In disorders of the blood, there is a reduced or missing blood
component or an inability of a component to function adequately. Sickle cell disease, thalassemia, and
hemophilia fall into this category. Chromosomal abnormalities number in the thousands. Most involve some
type of mental retardation, and others are incompatible with life. The newborn with Turners syndrome or
Klinefelters syndrome may have impaired physical growth and sexual development. Malformations at birth
include several types of structural defects.
DIF: Cognitive Level: Knowledge REF: Page 329
OBJ: 3 TOP: Classification of Birth Defects
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
25. What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.)
a. Close-set eyes
b. Simian creases
c. Wide-spaced front teeth
d. Protruding tongue
e. Curved, small fingers
ANS: A, B, D, E
Children with Down syndrome have close-set upturned eyes, simian creases in palms of hands, protruding
tongues, and curved, small fingers. They also have a wide space between their first and second toe and a high
incidence of heart defects.
DIF: Cognitive Level: Knowledge REF: PageN3U
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OBJ: 10 TOP: Features of Down Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?
(Select all that apply.)
a. Keep positioned with head elevated.
b. Feed slowly to reduce possibility of vomiting.
c. Stimulate often to maintain level of consciousness.
d. Hold and coddle frequently to stimulate.
e. Observe for increased intracranial pressure.
ANS: A, B, E
These children should be kept positioned with the head elevated, fed slowly, and monitored for increased
intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet
environment.
DIF: Cognitive Level: Comprehension REF: Page 350
TOP: Topic: Intracranial Hemorrhage KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
27. What would be included in the plan of care for a child just returned to the floor from surgery in which a
clubfoot was repaired? (Select all that apply.)
a. Keep cast uncovered to allow drying.
b. Check toes for capillary refill.
c. Circle with a pen any area of bleeding on the cast.
d. Keep casted leg lowered.
e. Observe for skin irritation.
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ANS: A, B, C, E
The casted leg should be kept elevated. All the other options are necessary nursing interventions for a child
who is freshly casted.
DIF: Cognitive Level: Comprehension REF: Page 336
OBJ: 2 TOP: Repair of Clubfoot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crackaddicted mother. What would be the manifestations of this syndrome? (Select all that apply.)
a. Body tremors
b. Excessive sneezing
c. Hyperirritability
d. Drowsiness
e. Excessive appetite
ANS: A, B, C
The neonate with abstinence syndrome will have tremors, be hyperirritable and wakeful, have excessive
sneezing or yawning, and have no appetite.
DIF: Cognitive Level: Knowledge REF: Page 350
TOP: Neonatal Abstinence KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
29. What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all
that apply.)
a. High-pitched cry
b. Inequality of pupils
c. Bulging fontanelles
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d. Diarrhea
e. Hiccups
ANS: A, B, C
Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles.
DIF: Cognitive Level: Knowledge REF: Page 331
OBJ: 14 TOP: Signs of ICP KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
30. The nurse is obtaining intake information on a new patient being seen for preconception care and notes a
family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent
neural tube anomalies in a developing fetus? (Select all that apply.)
a. Avoid drug use.
b. Follow a low-calorie, low-protein diet.
c. Take a folic acid supplement every day.
d. Exercise daily.
e. Maintain bed rest during the first trimester.
ANS: A, C
The use of drugs during early pregnancy and poor nutrition may contribute to the development of a neural tube
defect. The American Academy of Pediatrics (AAP) recommends that all women of childbearing age take a
daily multivitamin that contains 0.4 mg of folic acid and continue the intake of folic acid until the twelfth week
of pregnancy, when basic neural tube development is completed. Studies have shown that the intake of folic
acid before conception dramatically decreases the occurrence of neural tube defects such as spina bifida. Daily
exercise and bed rest do not decrease the risk of neural tube anomalies.
DIF: Cognitive Level: Comprehension REF: Page 333
OBJ: 5 TOP: Prevention of Neural Tube Defects
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KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
31. The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes
immediately after birth. What assessment findings can the nurse anticipate? (Select all that apply.)
a. High blood glucose levels
b. Weight of 9 pounds or more
c. Decreased subcutaneous fat
d. Hypocalcemia
e. Hyperbilirubinemia
ANS: B, D, E
Many newborn infants of diabetic mothers have serious complications. When the mother is hyperglycemic,
large amounts of glucose are transferred to the fetus. After delivery the infant often has low blood glucose
levels because of the abrupt loss of maternal glucose and hypertrophy of the pancreatic islet cells, which results
in a temporary overproduction of insulin. Hyperinsulinism, along with excess production of protein and fatty
acids, often results in a newborn infant who weighs more than 4082 g (9 lb). These infants suffer from
hypoglycemia, hypocalcemia, and hyperbilirubinemia.
DIF: Cognitive Level: Comprehension REF: Page 350
OBJ: 15 TOP: Macrosomic Newborn
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
32. The home health nurse is educating parents on home phototherapy. What will the nurse include when
providing information to these parents?
a. Cover the infants eyes when under the light.
b. Use a three-prong plug.
c. Keep a diaper in place.
d. Place the light source on an absorbent surfaN
ceU. RSINGTB.COM
e. Expose as much skin as possible.
ANS: B, C, E
Parents should be instructed to use a three-prong plug for safety, keep a diaper in place, and expose as much
skin as possible. The light source should be placed on a nonabsorbent surface, not on carpet or in a crib. It is
not necessary to cover the infants eyes when under the light.
DIF: Cognitive Level: Application REF: Page 348
OBJ: 13 TOP: Home Phototherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
COMPLETION
33. When the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting
hydrocephalus is diagnosed as
hydrocephalus.
ANS:
communicating
Communicating hydrocephalus occurs when the CSF is obstructed in the subarachnoid space rather than in the
ventricles.
DIF: Cognitive Level: Comprehension REF: Page 329
TOP: Communicating Hydrocephalus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
34. The nurse clarifies to the parents of a child with spina bifida that their child has a portion of the spinal cord
in the sac in addition to the meninges. This type of spina bifida is known as a(n)
.
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ANS:
meningomyelocele
A spina bifida that includes a portion of the cord in the sac in addition to the meninges is classified as a
meningomyelocele.
DIF: Cognitive Level: Comprehension REF: Page 332
TOP: Meningomyelocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
35. The nurse demonstrates how to flush the ventriculoperitoneal shunt by the use of the
that is in place behind the infants ear.
ANS:
pump
A small pump is part of the VP shunt. The pump is in place behind the childs ear. The shunt can be pumped
according to the physicians instructions to maintain flow from the ventricles to the peritoneum.
DIF: Cognitive Level: Comprehension REF: Page 330
TOP: Pumping the Shunt KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36. The initial treatment for cleft lip is a surgical repair known as
ANS:
cheiloplasty
The initial treatment for cleft lip is a surgical repair known as cheiloplasty.
DIF: Cognitive Level: Knowledge REF: PageN3U
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TOP: Cleft Lip Repair KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
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Chapter 15: An Overview of Growth, Development, and Nutrition
MULTIPLE CHOICE
1. What type of development is the nurse assessing when an infant can lift his or her head before he or she can
sit?
a. Specific to general
b. Proximodistal
c. Cephalocaudal
d. General to specific
ANS: C
Cephalocaudal development proceeds from head to toe.
DIF: Cognitive Level: Comprehension REF: Page 357
OBJ: 1 TOP: Cephalocaudal Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. What is a unique organization of characteristics that determines an individuals pattern of behavior?
a. Environment
b. Heredity
c. Personality
d. Experience
ANS: C
One definition of personality states that it is a unique organization of characteristics that determines the
individuals typical or recurrent pattern of behavior.
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TOP: Personality Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. An infants birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at 6 months?
a. 12 pounds
b. 15 pounds
c. 18 pounds
d. 22 pounds
ANS: B
An infant usually doubles his or her birth weight by 5 to 6 months.
DIF: Cognitive Level: Analysis REF: Page 357
OBJ: 4 TOP: Weight Prediction
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. What would the nurse further investigate when assessing patterns of growth in a child?
a. Previous weight was in the 75th percentile, and present weight is in the 25th percentile.
b. Height is in the 90th percentile, and weight is in the 75th percentile.
c. Last weight was in the 5th percentile, and present weight is in the 10th percentile.
d. Weight is in the 50th percentile, and siblings weight at the same age was in the 75th percentile.
ANS: A
The child showing a difference of two or more percentile levels from an established growth pattern should
undergo further evaluation.
DIF: Cognitive Level: Analysis REF: Page 360
TOP: Growth KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A mother reports that she and her husband have had one child together, but both have children from
previous marriages living in their home. The nurse will base the care planning on what type of family?
a. Nuclear
b. Blended
c. Alternate
d. Extended
ANS: B
A blended family involves the remarriage of persons with children.
DIF: Cognitive Level: Comprehension REF: Page 363
OBJ: 6 | 7 TOP: The Family KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. The mother of a 7-month-old reports that the first lower central incisor has erupted. She asks the nurse, How
many teeth will he have by his first birthday? The nurse explains that the infant will have how many teeth by 1
year of age?
a. 2
b. 4
c. 6
d. 8
ANS: C
The 1-year-old infant usually has about 6 teeth, 4 above and 2 below.
DIF: Cognitive Level: Knowledge REF: Page 384
TOP: Dentition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
Bt.C
7. At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first dental visit. What is
the nurses best response?
a. If the teeth are brushed regularly, the child should see a dentist by 3 years of age.
b. The first dental visit should be arranged after the first tooth erupts.
c. The child should have a dental examination when all deciduous teeth have erupted.
d. A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry.
ANS: D
The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year of age.
DIF: Cognitive Level: Application REF: Page 384
TOP: Dentition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. The nurse is planning anticipatory guidance for a caregiver of a preschool-age child. The nurse will explain
that permanent teeth begin erupting at what age?
a. 4 years old
b. 6 years old
c. 8 years old
d. 10 years old
ANS: B
Permanent teeth do not erupt through the gums until the sixth year.
DIF: Cognitive Level: Knowledge REF: Page 385
TOP: Dentition KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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9. A mother asks the nurse how much food should be offered to her 2-year-old. What is a good rule of thumb
for serving size (in tablespoons) per year of age?
a. 2
b. 3
c. 4
d. 5
ANS: A
The rule of thumb for serving sizes is to offer 1 tablespoon of each food group per year of age.
DIF: Cognitive Level: Comprehension REF: Page 384
TOP: Rule of Thumb for Serving Sizes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. An assessment of a childs nutritional status reveals the child is alert, with shiny hair, firm gums, firm
mucous membranes, and regular elimination. How would this childs nutritional status be described?
a. Overnourished
b. Undernourished
c. Well nourished
d. Borderline
ANS: C
Well-nourished children show steady gains in height and weight and have shiny hair, firm gums and mucous
membranes, and regular elimination.
DIF: Cognitive Level: Analysis REF: Page 383
TOP: Nutrition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse encourages a Puerto Rican famiN
lyUtR
oSbIrNinGgTfBo.oCdOtM
o a child because he is not eating the food
served on his hospital tray. What can the nurse expect the child to eat?
a. Dried beans mixed with rice
b. Crisp vegetables
c. Spaghetti and meatballs
d. Wild berries, roots, and seeds
ANS: A
A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice.
DIF: Cognitive Level: Comprehension REF: Page 376
OBJ: 7 TOP: Feeding the Ill Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. What does self-feeding
help to develop in the toddler?
a. Good nutrition
b. A sense of independence
c. Adequate height and weight
d. Healthy teeth
ANS: B
By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of
independence.
DIF: Cognitive Level: Comprehension REF: Page 372
OBJ: 2 TOP: Feeding the Healthy Child
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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13. What activity would the nurse choose to meet Eriksons developmental task of industry when caring for a 7year-old?
a. Completing a 50-piece jigsaw puzzle
b. Looking at a comic book
c. Playing a game of I Spy with the nurse
d. Coloring a picture in a coloring book
ANS: A
In the developmental period of late childhood, children are striving to develop a sense of industry. The
completion of a jigsaw puzzle is industrious play.
DIF: Cognitive Level: Analysis REF: Page 372
OBJ: 11 TOP: Personality Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. What does the nurse recognize as an example of Piagets concrete operational thinking?
a. 2-year-old says, Its nighttime when his room is darkened.
b. 4-year-old refers to the hospital as my house.
c. 5-year-old coloring a picture of a puppy says, This is my puppy.
d. 7-year-old says, I am sick because I have germs in my chest.
ANS: D
The 7-year-olds remark reflecting the cause and effect of germs and illness is an example of operational
thinking. All other options are examples of preoperational thought, which is egocentric and symbolic.
DIF: Cognitive Level: Analysis REF: Page 373
OBJ: 8 TOP: Cognitive Development
KEY: Nursing Process Step: Data Collection
Bt.C
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
15. The nurse has discussed with a mother the process of introducing solid foods to her 6-month-old infant.
What statement by the mother leads the nurse to determine that learning has taken place?
a. I will give my infant rice cereal first.
b. I will give my infant yellow vegetables first.
c. I will give my infant egg yolks first.
d. I will give my infant fruits first.
ANS: A
Solid foods are usually introduced at about 6 months of age, starting with rice cereal, which is the least
allergenic.
DIF: Cognitive Level: Comprehension REF: Page 379
OBJ: 9 TOP: Feeding the Healthy Child
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. What is the best nursing action when an 8-year-old child comes to the school nurse with his central incisor
in his hand and reports he knocked his tooth out on the water fountain?
a. Give him an ice cube to suck on.
b. Have him wash his mouth out with peroxide and water.
c. Wrap the tooth in a clean tissue.
d. Wash off the tooth and place it in a container of milk.
ANS: D
The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation.
DIF: Cognitive Level: Application REF: Page 387
OBJ: 10 TOP: Loss of Tooth
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
17. The mother of a 7-month-old states, The baby is eating food now. Should I give him regular milk, too?
What is the nurses best response?
a. You should give the baby low-fat milk.
b. Try the milk. See if he has any digestive problems.
c. Continue breast milk or iron-fortified formula until 1 year of age.
d. At this age, infants can tolerate lactose-free or soy-based milk.
ANS: C
Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2
years of age.
DIF: Cognitive Level: Application REF: Page 381
OBJ: 9 TOP: Nutrition and Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. When a small group of preschool-age children were playing house, each child was pretending to be a
particular family member. What type of play does the nurse recognize these children are participating in?
a. Parallel
b. Cooperative
c. Symbolic
d. Fantasy
ANS: B
In cooperative play, children play with each other, each taking a specific role.
DIF: Cognitive Level: Analysis REF: Page 38N
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OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. When the nurse asks a 10-year-old Native American if he is ready to go to therapy, he does not answer
immediately. How does the nurse interpret this response?
a. Indecision
b. Considering the answer in silence
c. Shyness with strangers
d. Fear of medical personnel
ANS: B
Native Americans value silence. They need to sit and consider matters before replying to questions.
DIF: Cognitive Level: Analysis REF: Page 371
OBJ: 7 TOP: Ethnic ConsiderationsAmerican Indian
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
20. A mother tells the nurse, My 11-month-old son is not as active as my other children were at this age. He is
the youngest of four and the older children love to dote on him. Which factor is influencing this childs
language development?
a. Heredity
b. Sex
c. Mothers health during pregnancy
d. Ordinal position
ANS: D
Motor development of the youngest child may be prolonged if the child is babied by others in the family.
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DIF: Cognitive Level: Analysis REF: Page 361
TOP: Factors Influencing Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. A mother tells her 4-year-old child that balls should be played with outside and not inside the house. Why
is the child likely to obey the rule?
a. The child does not want to be punished.
b. The child wants to please her mother.
c. The child respects authority figures.
d. The child believes that following the rules is right.
ANS: A
According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient to their parents for
fear of punishment.
DIF: Cognitive Level: Comprehension REF: Page 372
OBJ: 8 TOP: Moral Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. What should the nurse avoid when demonstrating a bath procedure to parents of Vietnamese origin?
a. Talking directly to the mother
b. Exposing the childs genitals
c. Touching the childs head
d. Using cool water
ANS: C
The Vietnamese are very sensitive about anyone touching a childs head because that is where consciousness
lies.
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DIF: Cognitive Level: Application REF: Page 367
OBJ: 7 TOP: Ethnic ConsiderationsVietnamese
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
23. What does the nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is 48 inches tall
(1.2 meters) and weighs 100 pounds (45.4 kg) to be?
a. 28.9
b. 32.4
c. 34.8
d. 37.6
ANS: B
The formula for BMI calculation is weight in kg divided by height in meters (squared):
45.4 (weight in kg) divided by 1.4 (1.2 squared) = 32.4. A BMI of over 30 is classified as obese.
DIF: Cognitive Level: Analysis REF: Page 383
OBJ: 9 TOP: Calculation of BMI
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24. What toy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old child?
a. Jack-in-the-box
b. Book of nursery rhymes
c. Model airport with toy planes
d. Model car construction kit
ANS: C
At this age children are into creative play. The model airport with toy planes is the most developmentally
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appropriate.
DIF: Cognitive Level: Application REF: Page 388
OBJ: 11 TOP: Play Activities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. The nurse caring for a 4-year-old postoperative patient instructs him to blow bubbles. What nursing
intervention is the nurse most likely implementing by using this form of therapeutic play?
a. Providing pain relief
b. Encouraging deep breathing
c. Decreasing risk of infection
d. Maintaining body temperature
ANS: B
Play can also be therapeutic and aid in the recovery process. An example of therapeutic play is the game of
having the child blow bubbles to promote deep breathing.
DIF: Cognitive Level: Application REF: Page 388
TOP: Therapeutic Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
26. The mother of a 7-year-old pediatric patient asks the nurse about her childs sleep requirement. What is the
most accurate response by the nurse?
a. 7 to 10 hours a night
b. 5 to 7 hours a night with one daytime nap
c. 11 to 13 hours a night
d. 4 to 6 hours a night with two daytime naps
ANS: C
NURSINGTB.COM
Sleep patterns vary with age. The neonate sleeps 8 to 9 hours per night and naps an equal amount of time
during the day. The 2-year-old may sleep 10 hours during the night and have only one short daytime nap. The
7-year-old usually requires 11 to 13 hours of sleep and rarely has a daytime nap. These patterns may be altered
by cultural practices.
DIF: Cognitive Level: Comprehension REF: Page 359
TOP: Sleep KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
MULTIPLE RESPONSE
27. How do children differ from adults? (Select all that apply.)
a. Higher metabolic rate
b. Greater surface area in relation to their weight
c. Less mature organ systems
d. More fluid reserves
e. Continuously changing growth and development pattern
ANS: A, B, C, E
Children are in a continuous growth and development pattern. Children have a greater surface area and a highe
metabolic rate. All of their organ systems are not mature.
DIF: Cognitive Level: Comprehension REF: Page 354
OBJ: 3 TOP: Adult Versus Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. What approaches should the nurse suggest for introducing a toddler to new foods? (Select all that apply.)
a. Serve one food at a time.
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b. Avoid showing personal likes or dislikes.
c. Offer foods in small amounts, less than a teaspoon.
d. Entice the toddler to eat with sweets.
e. Serve food warm.
ANS: A, B, C, E
Foods should be introduced in small, warm servings, one food at a time. Sweets and milk should not be offered
until after solid food.
DIF: Cognitive Level: Comprehension REF: Page 380
OBJ: 9 TOP: Solid Food KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29. Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select all that
apply.)
a. Bubble gum
b. Chocolate-covered peanuts
c. Raw vegetables
d. Cheese
e. Dried fruits
ANS: C, D
Cheese and raw vegetables are acceptable healthy snacks. Bubble gum, chocolate-covered peanuts, and dried
fruits all contain high amounts of sugar.
DIF: Cognitive Level: Comprehension REF: Page 380
OBJ: 9 TOP: Healthy Snacks
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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30. The nurse suggests to the parents of an obese 10-year-old that they use the Portion Plate for Kids placemat.
How does this tool help with selection of portion sizes? (Select all that apply.)
a. Cartoon characters eating healthy foods
b. Tips on healthy food choices
c. Portion measurement in tablespoons for common food
d. Calorie values for cup-size portions of common foods
e. Familiar objects such as a deck of cards to measure servings
ANS: B, E
The Portion Plate for Kids is a placemat that uses common objects such as a deck of playing cards or a basebal
to measure serving portions.
DIF: Cognitive Level: Comprehension REF: Page 377
OBJ: 9 TOP: Portion Plate for Kids
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. An educational program is being presented to pediatric nurses on the relationship of play to childhood
development. What information should be included in this presentation? (Select all that apply.)
a. Art play should be used sparingly.
b. Use of computer/video games is detrimental.
c. Understanding of child/parent relationships can be gained by observing play.
d. Play encourages self-expression.
e. Play provides a sense of accomplishment.
ANS: C, D, E
Art is an appropriate play activity at almost any age and provides an avenue for experimentation as well as for
creative expression and a feeling of accomplishment in the child. Observing the child at play can aid in
assessing growth and development and understanding the childs relationships with family members. Any plan
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of care for a hospitalized child of any age should include a play activity that either encourages growth and
development or encourages the expression of thoughts and feelings. Computer programs are popular with all
age groups, providing problem-solving skills, manipulative skills, and opportunities for new learning.
DIF: Cognitive Level: Comprehension REF: Page 387
OBJ: 12 | 15 TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32. Parents attending a well visit for their 11-year-old son verbalize concern over his computer use. When
asked about it, the boy states, I play games on my computer for 1 hour a day. The nurse knows that computer
games can provide what opportunities to childhood development? (Select all that apply.)
a. Problem-solving skills
b. Gross motor development
c. Manipulative skills
d. Learning opportunities
e. Increased self-worth
ANS: A, C, D
Computer programs are popular with all age groups, providing problem-solving skills, manipulative skills, and
opportunities for new learning.
DIF: Cognitive Level: Comprehension REF: Page 388
TOP: Computer Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
33. The nurse includes in the care plan for a Hispanic family to encourage visits from the
, or
for a healing ceremony.
NURSINGTB.COM
ANS:
folk healer, curandero
Hispanics have faith in the effect of the curandero and are soothed by the ceremonies.
DIF: Cognitive Level: Knowledge REF: Page 365
OBJ: 7 TOP: Folk Healer or Curandero
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
34. The nurse assesses an unmet need in a hospitalized child who clings to his mother as she is about to leave.
As described by Maslow, the basic needs that may be unmet in this case are
and
.
ANS:
love, belonging
The hospitalized child displaying these symptoms may feel a loss of love and a lack of belonging to the family
unit.
DIF: Cognitive Level: Knowledge REF: Page 364
OBJ: 8 TOP: Maslows Hierarchy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
35. The nurse cautions that children who are put to sleep with a bottle are at risk for a dental problem called
.
ANS:
nursing caries
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The bactericidal effects of saliva decrease during sleep; therefore, when the saliva and the milk combine, they
bathe the teeth in a mixture that encourages dental caries.
DIF: Cognitive Level: Knowledge REF: Page 386
OBJ: 9 TOP: Nursing Caries
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36. The correct term for the child aged 4 weeks to 1 year is
.
ANS:
infant
A child between the ages of 4 weeks and 1 year is termed an infant.
DIF: Cognitive Level: Knowledge REF: Page 356
TOP: Infant KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
37.
refers to standing measurement, whereas
a recumbent position.
refers to measurement while the infant is in
ANS:
Height, length
Height refers to standing measurement, whereas length refers to measurement while the infant is in a
recumbent position.
DIF: Cognitive Level: Knowledge REF: Page 357
TOP: Physical Development KEY: Nursing Process Step: Implementation
Bt.C
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
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Chapter 16: The Infant
MULTIPLE CHOICE
1. A mother calls the pediatricians office because her infant is colicky. What is the most helpful measure the
nurse can suggest to the mother?
a. Sing songs to the infant in a soft voice.
b. Place the infant in a well-lit room.
c. Walk around and massage the infants back.
d. Rock the fussy infant slowly and gently.
ANS: D
One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being
careful to avoid sudden movements.
DIF: Cognitive Level: Application REF: Page 400
OBJ: 7 TOP: Colic KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. When does the posterior fontanelle close?
a. 2 to 3 months
b. 3 to 6 months
c. 6 to 9 months
d. 9 to 12 months
ANS: A
The posterior fontanelle closes between 2 and 3 months of age.
DIF: Cognitive Level: Knowledge REF: Page 396
GaTtB
Co
OlM
OBJ: 5 TOP: Fontanelle KEY: Nursing ProcesNsUSRteSpIN
:D
a .C
lection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. At what age does an infants birth weight triple?
a. 9 months
b. 1 year
c. 18 months
d. 2 years
ANS: B
The infant usually triples his or her birth weight by about 12 months of age.
DIF: Cognitive Level: Knowledge REF: Page 400
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. What is the earliest age at which an infant is able to sit steadily alone?
a. 4 months
b. 5 months
c. 8 months
d. 15 months
ANS: C
The infant can sit alone without support at about 8 months of age.
DIF: Cognitive Level: Knowledge REF: Page 398
OBJ: 5 TOP: Sitting Alone
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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5. What is the earliest age at which the infant should be able to walk independently?
a. 8 to 10 months
b. 12 to 15 months
c. 15 to 18 months
d. 18 to 21 months
ANS: B
For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.
DIF: Cognitive Level: Knowledge REF: Page 400
OBJ: 5 TOP: Walk Independently
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a
cup? What is the nurses most accurate response?
a. 5 months
b. 9 months
c. 1 year
d. 2 years
ANS: A
The infant can usually drink from a cup when it is offered at about 5 months.
DIF: Cognitive Level: Comprehension REF: Page 397
TOP: Drink from Cup KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. What would the nurse expect a 4-month-old to be able to accomplish?
a. Hold a cup.
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b. Stand with assistance.
c. Lift head and shoulders.
d. Sit with back straight.
ANS: C
Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the
infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at
about 8 months.
DIF: Cognitive Level: Comprehension REF: Page 397
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. What is an abnormal finding in an evaluation of growth and development for a 6-month-old infant?
a. Weight gain of 4 to 7 ounces per week
b. Length increase of 1 inch in 2 months
c. Head lag present
d. Can sit alone for a few seconds
ANS: C
The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child
should undergo further evaluation.
DIF: Cognitive Level: Analysis REF: Page 397
OBJ: 3 TOP: Head Control
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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9. A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight
was 8 pounds, 2 ounces. What will the nurse weighing the infant today would expect her weight to be?
a. At least 12 pounds
b. At least 16 pounds
c. At least 20 pounds
d. At least 24 pounds
ANS: B
Birth weight is usually doubled by 6 months of age.
DIF: Cognitive Level: Application REF: Page 397
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. What will the nurse advise a parent to do when introducing solid foods?
a. Begin with one tablespoon of food.
b. Mix foods together.
c. Eliminate a refused food from the diet.
d. Introduce each new food 4 to 7 days apart.
ANS: D
Only one new food is offered in a 4- to 7-day period to determine tolerance.
DIF: Cognitive Level: Comprehension REF: Page 407
TOP: Solid Food KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. The nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are the first
deciduous teeth to erupt?
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a. Lower central incisors
b. Upper central incisors
c. Lower lateral incisors
d. Upper lateral incisors
ANS: A
The first teeth to erupt, usually at about 7 months, are the lower central incisors.
DIF: Cognitive Level: Knowledge REF: Page 398
OBJ: 5 TOP: Development and Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12. The nurse is assessing development in a 9-month-old infant. What would the nurse expect to observe?
a. Speaking in 2-word sentences
b. Grasping objects with palmar grasp
c. Creeping along the floor
d. Beginning to use a spoon rather sloppily
ANS: C
The 9-month-old tries to creep, has developed pincer movement, and can grasp a spoon without keeping food
on it.
DIF: Cognitive Level: Analysis REF: Page 399
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. What statement made by a parent indicates correct understanding of infant feeding?
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a. Ive been mixing rice cereal and formula in the babys bottle.
b. I switched the baby to low-fat milk at 9 months.
c. The baby really likes little pieces of chocolate.
d. I give the baby any new foods before he takes his bottle.
ANS: D
New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.
DIF: Cognitive Level: Comprehension REF: Page 407
OBJ: 15 TOP: Nutrition Counseling
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. A mother is concerned because her 10-month-old is lethargic. What is the best action the nurse can advise
this mother to implement?
a. Keep the infants room well lit.
b. Rub the infants soles vigorously.
c. Offer the infant a pacifier.
d. Handle the infant slowly and gently.
ANS: D
Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and
gently.
DIF: Cognitive Level: Application REF: Page 401
TOP: Lethargy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15. The nurse discusses child-proofing the home for safety with the mother of a 9-month-old. Which statement
made by the mother would indicate an unsafe N
beUhRaSvIiN
orG?TB.COM
a. I put covers on all of the electrical outlets.
b. In the car, she rides in a front-facing car seat.
c. There are locks on all of the cabinets in the house.
d. I have a gate at the top and bottom of the stairs.
ANS: B
A rear-facing infant car seat should be used for infants younger than 1 year of age.
DIF: Cognitive Level: Analysis REF: Page 409
TOP: Infant Safety KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
16. The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces of cereal.
What does this behavior indicate the infant has developed?
a. The pincer grasp
b. A grasp reflex
c. Prehension ability
d. The parachute reflex
ANS: A
By 1 year, the pincer-grasp coordination of index finger and thumb is well established.
DIF: Cognitive Level: Comprehension REF: Page 393
OBJ: 3 TOP: General Characteristics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. A parent is concerned because her infant has a diaper rash. What is the best action the nurse would advise
the parent to implement?
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a. Use commercial diaper wipes to clean the area.
b. Apply a protective ointment on the area.
c. Change the infants diaper less frequently.
d. Keep the diaper area covered all of the time.
ANS: B
A protective ointment can be applied when the skin in the diaper area appears pink and irritated.
DIF: Cognitive Level: Application REF: Page 402
TOP: Diaper Rash KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
18. The mother of an infant born prematurely tells the nurse, The baby is irritable. She cries during diaper
changes and feedings. Can you make some suggestions about what I should do to soothe her? What is the most
appropriate recommendation to help this parent?
a. Play the radio or TV while you feed the infant.
b. Put the infant in a room with sunlight.
c. Wrap the infant snugly when you hold them.
d. Change the infants position quickly.
ANS: C
A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and
hands near the face.
DIF: Cognitive Level: Application REF: Page 400
OBJ: 7 TOP: Infant Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19. What is the most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1year-old?
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a. Ride a tricycle.
b. Spend time in an infant swing.
c. Play with push-pull toys.
d. Read large picture books.
ANS: C
Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child.
DIF: Cognitive Level: Analysis REF: Page 410
OBJ: 18 TOP: Infant Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. Which statement indicates the mother of an 8-month-old understands infant sleep patterns?
a. I put the baby in my bed until she falls asleep, then I put her in her crib.
b. I let the baby skip an afternoon nap so that she will fall asleep earlier.
c. I put the pacifier in the crib so that she can find it when she wakes up.
d. I rock the baby back to sleep if she wakes up at night.
ANS: C
The parent should assist the infant to develop self-soothing behaviors so that the infant can get back to sleep on
her own.
DIF: Cognitive Level: Analysis REF: Page 402
TOP: Sleep Patterns KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. How might the nurse demonstrate the parachute reflex with an infant?
a. Lifting the infant high in the air above her head
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b. Holding the infant in a football hold, cradling the head
c. Seating the infant in a stroller in an upright position
d. Thrusting the infant downward into the crib
ANS: D
The infant, when thrust downward in a prone position, will protectively extend the arms.
DIF: Cognitive Level: Comprehension REF: Page 393
TOP: Parachute Reflex KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. Parents of a 6-month-old infant ask the nurse why it is necessary to offer iron-rich formula to their child.
What is the correct response?
a. The infant has limited ability to produce red blood cells.
b. The infant has ineffective digestive enzymes.
c. The infant has exhausted maternal iron stores.
d. The infant has need of the iron to support dentition.
ANS: C
Many pediatricians recommend iron-fortified formulas because maternal iron stores decrease by 6 months of
age.
DIF: Cognitive Level: Comprehension REF: Page 404
TOP: Iron Supplement KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23. The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the
physician immediately?
a. Respiratory rate of 60 breaths per minute
b. Pulse rate of 100 beats per minute
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c. Minimal verbalization
d. Fussy behavior
ANS: A
Respirations of a 1-year-old should be 20 to 40 breaths per minute. Increased respiratory rate can lead to
distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal
verbalization and fussy behavior are not emergency situations or abnormal for this age.
DIF: Cognitive Level: Application REF: Page 400
OBJ: 2 TOP: 12-Month-Old Physical Characteristics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24. A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does the
nurse instruct this mother she should expect her newborn to feed?
a. Every 2 to 3 hours
b. Every 4 to 6 hours
c. Every 6 to 8 hours
d. Every 8 to 10 hours
ANS: A
Breastfed infants may require feedings at 2- to 3-hour intervals because breast milk is more easily digested. A
flexible but regular schedule that provides a rest period between feedings is best for the parent and infant.
DIF: Cognitive Level: Application REF: Page 403
TOP: 12-Month-Old Physical Characteristics
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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MULTIPLE RESPONSE
25. The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)?
(Select all that apply.)
a. Irritability
b. Ineffective feeding patterns
c. No predictable sleep-wake cycle
d. Distrust
e. Effective parent bonding
ANS: A, B, C, D
Children who experience frequent hunger do not have effective parental bonding. All other options are
probable outcomes for a child who has unmet hunger needs.
DIF: Cognitive Level: Comprehension REF: Page 404
OBJ: 3 TOP: Hunger KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. The nurse is preparing to outline principles of discipline for parents of an infant. What information should
the nurse include? (Select all that apply.)
a. Firmly say No.
b. Distract the child to another activity.
c. Bribe the child with a sweet treat.
d. Remain consistent.
e. Ignore the child until behavior improves.
ANS: A, B, D
Parental approval is important to the infant, and setting limits early is important (Anderson, 2008). Principles
of discipline for an infant include lowering the voice to say no firmly, removing the child from the situation,
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distraction, and consistency.
DIF: Cognitive Level: Comprehension REF: Page 393
OBJ: 4 TOP: Discipline KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. What should the teaching plan include about infant fall precautions? (Select all that apply.)
a. Remove all unsteady furniture.
b. Keep crib rails up and in locked position.
c. Steady infant with hand when on changing table.
d. Use tray attachment on high chair as restraint.
e. Keep infant seat on the floor.
ANS: A, B, C, E
The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent
an infant from a fall.
DIF: Cognitive Level: Comprehension REF: Page 409
TOP: Fall Prevention KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
28. The nurse is aware that the 7-month-old can signal feeding readiness by which action(s)? (Select all that
apply.)
a. Pulling spoon toward mouth
b. Biting at spoon with upper and lower incisors
c. Pointing to food bowl
d. Bouncing up and down with excitement at sight of food
e. Manipulating finger foods
ANS: A, E
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The 7-month-old pulls the spoon toward his or her mouth and can manipulate finger foods. The 7-month-old
does not have upper incisors and has not developed adequately to recognize the food container or exhibit
excitement related to the sight of food.
DIF: Cognitive Level: Comprehension REF: Page 404
OBJ: 3 TOP: Feeding Skills
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29. The nurse is educating parents of a 2-month-old about immunizations. What immunizations against illness
should their child receive? (Select all that apply.)
a. Pertussis (whooping cough)
b. Influenza
c. Diptheria
d. Tetanus
e. Polio
ANS: A, B, C, D, E
The first DPT, polio, and flu immunizations are given at the age of 2 months.
DIF: Cognitive Level: Knowledge REF: Page 396
OBJ: 6 TOP: Immunizations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
30. What will the nurse take into consideration when educating parents regarding infant nutrition? (Select all
that apply.)
a. Cultural practices
b. Sex of the infant
c. Parental knowledge
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d. Infants developmental level
e. Parent-child interaction
ANS: A, C, D, E
Parents have many concerns about feeding their infant during the first year of life. This is a period when
readiness to receive nutrition education is usually high; therefore the nurse looks for opportunities to provide
accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parentchild interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional
education.
DIF: Cognitive Level: Comprehension REF: Page 403
OBJ: 10 TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. Parents of an infant inform the nurse they are planning home preparation of solid foods. What directions
should the nurse provide? (Select all that apply.)
a. Boil foods in a large amount of water.
b. Do not freeze foods.
c. Add 1 teaspoon of salt per cup.
d. Puree food in electric blender.
e. Add sugar sparingly.
ANS: D, E
Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly.
Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may
be frozen in ice cube trays and defrosted for use.
DIF: Cognitive Level: Comprehension REF: Page 407
OBJ: 12 | 13 TOP: Nutrition KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
32. The nurse explains that the second process of self-mobility an infant learns is seen at the age of 9 months,
when the infant begins to
.
ANS:
creep
At 7 months the infant begins to crawl, using arms and dragging trunk and legs. At 9 months the infant begins
to creep, holding his or her trunk above the floor. The next self-mobility activity is cruising, where the child
walks from one piece of furniture to the next before it begins to walk independently.
DIF: Cognitive Level: Application REF: Page 395
OBJ: 3 TOP: Creeping KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. The nurse cautions parents to place their infant in the
stomach, to reduce the risk of sudden infant death syndrome (SIDS).
position, rather than on his or her
ANS:
supine
The supine or side-lying position has been found to reduce possible aspiration and is believed to reduce the risk
of SIDS.
DIF: Cognitive Level: Application REF: Page 401
TOP: Positions for Sleep KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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34.
is characterized by periods of unexplained irritability and crying in a healthy, well-fed
infant.
ANS:
Colic
Colic is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant.
DIF: Cognitive Level: Knowledge REF: Page 401
TOP: Colic KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. The nurse explains that an infants prehensile development is progressive and logical. Arrange the
development in the order from the simplest to the most complex. Put a comma and space between each answer
choice (a, b, c, d, etc.)
a. Hands held open most of the time
b. Grasps with thumb on one side and three fingers on the other
c. Picks up toy with squeeze action
d. Thumb and forefinger hold object
e. Hands held closed most of the time
ANS:
E, A, C, B, D
The development advances from the newborns closed hands to the open star hands of the older infant, to the
squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.
DIF: Cognitive Level: Analysis REF: Page 394
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OBJ: 3 TOP: Prehensile Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 17: The Toddler
MULTIPLE CHOICE
1. Which behavior reported by a parent of an 18-month-old toddler would the nurse report to the pediatrician
as a cause for concern?
a. Has temper tantrums
b. Feeds self sloppily
c. Walks by holding onto furniture
d. Speaks in short sentences
ANS: C
By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding
onto furniture should be evaluated by a developmental specialist.
DIF: Cognitive Level: Analysis REF: Page 413
OBJ: 2 TOP: Delayed Walking
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. What would the nurse assessing growth and development of a 2-year-old child expect to find?
a. The child jumps with both feet.
b. Twenty deciduous teeth have erupted.
c. The child can hop on one foot.
d. The child has a vocabulary of 900 words.
ANS: A
The 2-year-old can jump with both feet. The remaining achievements occur after 2 years of age.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS4I1N3GTB.COM
OBJ: 2 TOP: Jumping KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. A parent remarks, My 18-month-old daughter carries her blanket around everywhere. Is this normal? What
is the best explanation a nurse who has an understanding of toddler development might give?
a. She carries her blanket because she is ritualistic.
b. Carrying her favorite blanket is self-consoling behavior.
c. This behavior can be discouraged by offering new toys to the child.
d. This could be indicative of emotional distress.
ANS: B
Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler.
DIF: Cognitive Level: Application REF: Page 412
OBJ: 6 TOP: Self Consoling
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse observed three toddlers playing side by side with dolls. Closer observation revealed that the
children were not interacting with one another. What type of play is this?
a. Solitary
b. Parallel
c. Associative
d. Cooperative
ANS: B
Toddlers engage in parallel play. Children play next to, but not with, each other.
DIF: Cognitive Level: Comprehension REF: Page 424
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TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. What instruction would the nurse include when planning anticipatory guidance for parents of a toddler?
a. Adhere to a rigid schedule because the toddler is ritualistic.
b. Limit-setting should include praise.
c. Shoes should fit snugly at the toe and arch.
d. Dress the toddler in pants with a zipper so that he or she can learn to zip and unzip clothes.
ANS: B
Limit-setting should include praise as well as disapproval for undesired behavior.
DIF: Cognitive Level: Application REF: Page 416
TOP: Limit Setting KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. What is the best advice the nurse can offer a parent concerned because her 2-year-old is very active and does
not eat much?
a. Insist that the child eat one food on the plate.
b. Help the child wind down with a quiet activity before mealtime.
c. Maintain a consistent eating schedule for the family.
d. Serve the meal with a variety of interesting plates, cups, and utensils.
ANS: B
Quiet time before meals provides an opportunity for the active toddler to wind down.
DIF: Cognitive Level: Application REF: Page 419
TOP: Quiet Time KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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7. How would the nurse advise a parent who states, I never know how much food to feed my child?
a. Serving sizes should not exceed 1 teaspoon of each type of food.
b. Food quantities must be carefully measured to avoid overfeeding.
c. Use 1 tablespoon of each food for each year of age as a guideline.
d. A toddler should eat three balanced meals. Snacks are not necessary.
ANS: C
A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving
sizes.
DIF: Cognitive Level: Application REF: Page 419
TOP: Food Portions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. The nurse is discussing toilet training with parents. What behavior by the child would identify toilet training
readiness?
a. Willing to sit on the potty for 15 to 20 minutes
b. Dry in the daytime for 4-hour periods
c. Able to communicate that he or she is wet
d. Curious about bathroom activities
ANS: C
Children are ready for toilet training when they can communicate in some fashion that they are wet or need to
urinate or defecate.
DIF: Cognitive Level: Comprehension REF: Page 417
OBJ: 8 TOP: Toilet Independence
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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9. What is the most appropriate toy for the nurse to select for a normal 2-year-old child?
a. Bicycle with training wheels
b. Dump truck
c. Wind-up toy
d. Building block set
ANS: B
The 2-year-old enjoys playing with objects that can be pushed or pulled.
DIF: Cognitive Level: Application REF: Page 424
TOP: Toys and Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. What could the nurse recommend to a childs mother to encourage a toddler to practice independence?
a. Offer a variety of items to choose from to stimulate his mind.
b. Allow the child to determine his own daily routine.
c. Offer him a choice between two items.
d. Set the routine herself, but discuss with her toddler how he or she would have done it differently.
ANS: C
The toddler can be allowed to make choices as the situation warrants, but the number of choices should be
limited because too many confuse the toddler.
DIF: Cognitive Level: Application REF: Page 412
TOP: Offering Choices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. On a home visit, the nurse notes that the parents require teaching intervention to protect the 15-month-old
child who lives there. What observation would lead the nurse to this conclusion?
a. The fireplace has a screen.
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b. The dining room table has a tablecloth on it.
c. There are paintings on the wall.
d. The kitchen floor is clean but not shiny.
ANS: B
A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it. The toddler could
be injured if items on the table are moved when the tablecloth is pulled.
DIF: Cognitive Level: Analysis REF: Page 421
OBJ: 10 TOP: Injury Prevention
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
12. What does the nurse consider as an appropriate snack for a 2-year-old child?
a. Hot dog sections
b. Grapes
c. Popcorn
d. Applesauce
ANS: D
Applesauce is a healthy and safe snack food for the toddler. The toddler is at risk for choking on foods such as
grapes, hot dogs, and popcorn.
DIF: Cognitive Level: Analysis REF: Page 421
OBJ: 10 TOP: Injury Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. Which finding would concern the nurse assessing vital signs on a 2-year-old?
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a. Temperature of 37.1 C (98.8 F)
b. Pulse at 100 beats/min
c. Respirations of 36 breaths/min
d. Blood pressure of 90/60 mm Hg
ANS: C
In the toddler period, the respiratory rate decreases to 25 breaths/min.
DIF: Cognitive Level: Analysis REF: Page 414
TOP: Vital Signs KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. What would be an expected finding when assessing language development in a 2-year-old?
a. A 900-word vocabulary
b. Use of two-word sentences
c. Use of pronouns and prepositions
d. 100% of speech is understandable
ANS: B
The 2-year-old should be using two-word sentences.
DIF: Cognitive Level: Analysis REF: Page 415
OBJ: 5 TOP: Speech Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. The nurse is planning to explain the use of time-outs to the parent of a 3-year-old. How many minutes will
the nurse indicate is appropriate for a child of this age?
a. 3
b. 6
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c. 10
d. 15
ANS: A
Timing for time-out is usually based on 1 minute per year of age.
DIF: Cognitive Level: Comprehension REF: Page 416
TOP: Guidance and Discipline KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. The parent of a toddler tells the nurse, My daughters appetite has decreased. Thank goodness she loves to
drink milk. What is the most appropriate response by the nurse?
a. Has your daughter been sick recently?
b. How much milk does she drink in a day?
c. Has she become a fussy eater, too?
d. Have you tried offering her finger foods?
ANS: B
Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies of iron.
DIF: Cognitive Level: Application REF: Page 419
TOP: Nutrition Counseling KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
17. How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to begin bladde
training?
a. 1
b. 2
c. 3
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d. 4
ANS: B
If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.
DIF: Cognitive Level: Comprehension REF: Page 418
TOP: Bladder Training KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. Parents tell the nurse they are frustrated with their toddlers recent behavior and refusal to agree with
anything they ask of them. What does the nurse explain as the term for when a toddler tests their own power?
a. Negativism
b. Dawdling
c. Tantrums
d. Food fads
ANS: A
By refusing to eat, dress, sleep, or anything else by saying No, toddlers test their own power to control.
Because toddlers are also egocentric, they come to believe that their negativism is absolute. This is especially
true if the adults give into it.
DIF: Cognitive Level: Comprehension REF: Page 412
TOP: Negativism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. The nurse is assessing a 3-year-old. What is the expected weight gain for this age child?
a. 2 times the birth weight
b. 2.5 times the birth weight
c. 3 times the birth weight
d. 4 times the birth weight
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ANS: D
The expected weight of a -year-old toddler is four times the birth weight.
DIF: Cognitive Level: Comprehension REF: Page 412
TOP: Weight Prediction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. What guideline should an adult follow when speaking to a toddler?
a. Be at eye level with the child.
b. Hold by the shoulders to keep the childs attention.
c. Seat the child to focus on conversation.
d. Speak in a firm strong voice.
ANS: A
Being at eye level is helpful to hold the childs attention and is especially important when the child is
frightened.
DIF: Cognitive Level: Comprehension REF: Page 416
TOP: Conversing with Toddler KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. Why does day care for the toddler differ from that of the preschooler?
a. Toddlers have a shorter attention span.
b. Toddlers need more group play.
c. Toddlers are less prone to environmental dangers.
d. Toddlers require less outdoor space.
ANS: A
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Toddlers have a shorter attention span than preschoolers and are prone to investigate other opportunities in the
environment that may put them in harms way. Toddlers are more interested in parallel play.
DIF: Cognitive Level: Comprehension REF: Page 420
TOP: Day Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. A 16-month-old child is attending a well-child visit at a pediatric clinic. Which assessment would indicate
the biggest cause for concern?
a. Does not walk independently
b. Prefers finger feeding
c. Limited to single words
d. Is unable to climb steps
ANS: A
A child should be walking independently by 16 months old. It is normal for a child this age to prefer finger
feeding and to be limited to single words. Many children do not climb steps until 24 months of age.
DIF: Cognitive Level: Comprehension REF: Page 413
OBJ: 2 TOP: Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
23. When selecting a potty chair, the parents are encouraged to select one that has which characteristic(s)?
(Select all that apply.)
a. Small enough for the childs feet to touch floor
b. Sturdy and stable
c. Supportive of childs back and arms
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d. Made of plastic or fiberglass
e. Capable of being taken apart easily
ANS: A, B, C
Potty chairs should be small and sturdy and supportive of the childs back and arms. The composition is not
important as long as it is stable.
DIF: Cognitive Level: Comprehension REF: Page 418
TOP: Potty Chairs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24. The nurse suggests offering which food(s) to support the toddlers desire to self-feed? (Select all that apply.)
a. Pureed foods
b. Finger foods
c. Foods served cold
d. Foods in colorful dishes
e. Foods that are varied and colorful
ANS: B, D, E
Finger foods that are varied and colorful and served in colorful dishes at a moderate temperature are all
attractive. Foods can be chopped into small pieces but not pureed.
DIF: Cognitive Level: Comprehension REF: Page 419
TOP: Self-Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. The nurse points out which physiological change(s) in the toddler that serve(s)as protection against
disease? (Select all that apply.)
a. Toughening of the skin
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b. Increased capillary response for thermoregulation
c. Stabilization of body temperature
d. Elevation in white blood cell count
e. Enlarged adenoids and tonsils
ANS: A, B, C, E
With the exception of an increased white blood cell (WBC) count, which is always pathological, the other
options are all maturing changes that equip the toddler to better fight disease.
DIF: Cognitive Level: Comprehension REF: Page 413
TOP: Physiological Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. Parents of a toddler are discussing the emotion of fear with the pediatric nurse. What information can the
nurse offer regarding fear and the toddler? (Select all that apply.)
a. Stress increases fear.
b. Rituals help deal with fear.
c. Teasing the child can decrease fear.
d. Once fear is learned it is difficult to eliminate.
e. Adults should openly share their fears.
ANS: A, B, D
Once a fear has been learned, it is more difficult to eliminate. Clinging to favorite possessions and repetitive
rituals are self-consoling behaviors for the toddler, particularly at bedtime and during separation from parents.
Stress increases fear of separation. Adults should attempt to control their own fears in the presence of young
children. Respect and understanding should always be accorded to children who are afraid. Making fun of the
fear or shaming the child in front of others is detrimental to self-esteem.
DIF: Cognitive Level: Comprehension REF: Page 416
TOP: Fear KEY: Nursing Process Step: ImpleN
mUeR
ntSaItN
ioGnTB.COM
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
27. The nurse assessing a 2-year-old is satisfied to see that the present weight of the child is
the birth weight.
ANS:
triple
The birth weight has usually tripled by the time the child is 2 years of age.
DIF: Cognitive Level: Comprehension REF: Page 412
TOP: Tripled Birth Weight KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. The nurse explains that with the completion of myelination, the toddler will have the neuromuscular
maturity to attain
or
control.
ANS:
bowel, bladder
With the mature myelin, the toddler is able to translate neural impulses and respond in a significant manner.
With myelination, the toddler can now translate the feeling of a full bladder or bowel and respond by
defecating or urinating at willhopefully in the bathroom.
DIF: Cognitive Level: Comprehension REF: Page 413
TOP: Myelination KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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29. The nurse recognizes that when the toddler claims everything in the environment as mine, it is an example
of the toddler trait of
.
ANS:
egocentrism
Toddlers are egocentric in that they perceive their world only as it applies to them, such as MY mommy, MY
dog, MY car, MY house, MY street. As they mature and have more experience with the world, they come to a
more realistic viewpoint.
DIF: Cognitive Level: Comprehension REF: Page 424
OBJ: 2 TOP: Egocentrism KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30. When the previously potty-trained 3-year-old wets the bed after admission to the hospital, the nurse
assesses this event is caused by a
related to the new environment.
ANS:
regression
Regression occurs when a situation causes the person to go back to a less mature manner of coping. Faced with
the new situation, in this case a hospital admission, the toddler reverts to an earlier coping mechanism in which
potty training has no part. The same regression frequently appears when a new infant is introduced to the
family circle, or when a traumatic event such as a death or divorce affects the family
DIF: Cognitive Level: Comprehension REF: Page 418
TOP: Toddler Regression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
31. The toddler is in Eriksons stage of
versus
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.
ANS:
autonomy; shame and doubt
The toddler is in Eriksons stage of autonomy versus shame and doubt, which is based on a continuum of trust
established during infancy
DIF: Cognitive Level: Knowledge REF: Page 412
TOP: Eriksons Stages KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32.
routines of simple tasks.
is when toddlers increase their sense of security by making compulsive
ANS:
Ritualism
Ritualism is when toddlers increase their sense of security by making compulsive routines of simple tasks.
DIF: Cognitive Level: Knowledge REF: Page 412
TOP: Ritualism KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. Put the developmental milestones in order from first achieved to last achieved. Put a comma and space
between each answer choice (a, b, c, d, etc.)
a. Jumps with both feet
b. Holds a cup by the handle
c. Social smile
d. Babbles
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e. Understands no
ANS:
C, D, E, A, B
Social smile: 2 months
Babbles: 3 months
Understands no: 9 months
Jumps with both feet: 24 months
Holds a cup by the handle: 36 months
DIF: Cognitive Level: Analysis REF: Page 413
OBJ: 3 TOP: Physical Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 18: The Preschool Child
MULTIPLE CHOICE
1. Which statement best describes the 3-year-old child?
a. Boisterous, tattles on others
b. Aggressive, shows off
c. Helpful, wants to assist with chores
d. Talkative, inquisitive about the environment
ANS: C
Three-year-old children are helpful and can assist in simple household chores.
DIF: Cognitive Level: Comprehension REF: Page 431
TOP: Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis.
What knowledge would act as the basis for the nurses response?
a. This behavior indicates a normal curiosity about sexuality.
b. Masturbation suggests the boy has an excessive fear of castration.
c. It is usually a result of discomfort from a penile rash or irritation.
d. The behavior is abnormal and the child should be referred for counseling.
ANS: A
Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality.
DIF: Cognitive Level: Comprehension REF: Page 431
TOP: Masturbation KEY: Nursing Process Step: Implementation
Bt.C
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INGGroTw
hO
anMd Development
3. A preschool-age child is asked, Why do trees have leaves? Which response would be an example of
animism?
a. So I can have shade over my sandbox.
b. Because God made them that way.
c. To hide behind when they are scared.
d. For the squirrels to play in.
ANS: C
Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects.
DIF: Cognitive Level: Application REF: Page 428
TOP: Cognitive Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. What tasks would be appropriate to expect of a 5-year-old?
a. Setting the table with paper plates
b. Washing the dirty knives
c. Carrying glasses from the table to the sink
d. Scrubbing out the sink with cleanser
ANS: A
Parents must consider developmental level and safety when asking the 5-year-old child to help with chores.
DIF: Cognitive Level: Application REF: Page 437
TOP: DevelopmentSafety KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A 3-year-old child, while playing with his favorite toy in the playroom of the pediatric unit, is approached
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by another child who also wants to play with the same toy. What behavior will the nurse anticipate from this
child?
a. Will play well with the other child
b. Will give the toy up and then not play anymore
c. Will become angry and a physical response might ensue
d. Will ignore the toy and go on to something else
ANS: C
The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her
possessions.
DIF: Cognitive Level: Application REF: Page 432
TOP: Display of Aggression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. A parent is concerned about her childrens reaction should their grandmother die. What understanding will
guide the nurses response?
a. Children are unlikely to notice their grandmothers absence if no one reminds them.
b. Young children often understand that other people die, but do not equate it with themselves.
c. The childrens response will depend entirely on whether they have been acquainted with death before this.
d. Children can understand the concept of a higher being much like adults can.
ANS: B
Between 3 and 4 years of age, the child becomes curious about death and dying. They may realize that others
die, but they do not relate death to themselves.
DIF: Cognitive Level: Comprehension REF: Page 432
TOP: Concept of Death KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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7. What is the most appropriate intervention when dealing with occasional aggression in a 4-year-old child?
a. Have the child take a time-out in the corner for 4 minutes.
b. Spank the child at the time of the incident.
c. Take away television privileges for the day.
d. Send the child to his room for 30 minutes.
ANS: A
Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are
considered an effective disciplinary technique.
DIF: Cognitive Level: Application REF: Page 432
TOP: Limit Setting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. A father is concerned about how long his preschool-age child will continue sucking his thumb. What is the
most helpful response from the nurse?
a. Most children will stop thumb-sucking naturally by school age.
b. Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice.
c. Consistently touching the childs fingers whenever he sucks his thumb is most effective.
d. Thumb-sucking is detrimental to the eruption of the childs teeth and must be stopped as soon as possible.
ANS: A
Most children give up the habit of thumb-sucking by the time they reach school.
DIF: Cognitive Level: Application REF: Page 435
TOP: Thumb-Sucking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. How does the nurse characterize the play of 5-year-old children?
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a. Enjoying rough and tumble play
b. Playing well-organized games
c. Following rules
d. Preferring inside activities
ANS: C
The 5-year-old wants to play by the rules but cannot accept losing. The rules may be very strict or change as
the game progresses.
DIF: Cognitive Level: Comprehension REF: Page 429
OBJ: 13 TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. The nurse is discussing preschoolers sexual curiosity with the parent. What statement by the mother leads
the nurse to determine that the mother understands the information?
a. Make up funny words for body parts.
b. Distract the child with a toy if they ask about sex.
c. Answer their questions when they ask.
d. Tell them to ask you again when they are 6 year old.
ANS: C
Parents should provide sex education at the time the child asks about sex.
DIF: Cognitive Level: Analysis REF: Page 431
TOP: Sexual Curiosity KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. What type of play is most appropriate when planning care for a child with moderate intellectual
deficiency?
a. Exercise leg and arm muscles.
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b. Be educationally oriented to make up for lost time.
c. Be adjusted to mental age rather than chronological age.
d. Involve contact sports and aggressive physical activity with other children.
ANS: C
The nurse must consider the childs mental age rather than her chronological age when selecting toys for play.
DIF: Cognitive Level: Application REF: Page 438
TOP: Play KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12. What is the nurses best advice to a parent about a preschoolers imaginary friend?
a. Having imaginary friends is a sign that the child has low self-esteem.
b. It is common for preschoolers to have imaginary friends.
c. Preschoolers invent an imaginary friend when they feel overwhelmed.
d. The best approach to dealing with an imaginary friend is to ignore them.
ANS: B
Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief
from loneliness, mastery of fears, and acting as a scapegoat.
DIF: Cognitive Level: Comprehension REF: Page 438
OBJ: 13 TOP: Imaginary Friend
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. What intervention might the nurse suggest as helpful for the child with enuresis?
a. Applying an electric pad that gently shocks the child
b. Waking the child several times during the night to urinate
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c. Decreasing fluid intake after the evening meal
d. Increasing dietary fiber intake
ANS: C
If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void
before going to bed.
DIF: Cognitive Level: Application REF: Page 435
OBJ: 9 TOP: Enuresis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. What should the nurse suggest as the most appropriate toy choice for a 3-year-old?
a. A board game
b. A small pet, such as a goldfish
c. A large construction set
d. Push-pull toys
ANS: C
Large construction sets are suitable toys for the preschool-age child.
DIF: Cognitive Level: Application REF: Page 438
TOP: Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. The parent of a 3 -year-old child tells the nurse, My daughter points instead of speaking whenever she
wants me to get something for her, but she understands me when I ask her to do something. Based on the
parents comment, what does the nurse suspect?
a. Age-appropriate language development
b. An expressive language delay
c. A receptive language delay
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d. A potential hearing deficit
ANS: B
An expressive language delay is suspected when the child understands spoken language but is not talking.
DIF: Cognitive Level: Application REF: Page 432
OBJ: 3 TOP: Language Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. The parent of a 4 -year-old child tells the nurse, Bedtime is difficult. I cant get my son to go to bed at night.
The nurse and the childs mother discuss options. What intervention is the most appropriate choice?
a. Allow the child to put himself to bed when he is tired.
b. Let the child read in his room until he falls asleep.
c. Establish a bedtime routine and use it consistently.
d. Tire him out with physical activity before bedtime.
ANS: C
Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness
for bedtime.
DIF: Cognitive Level: Application REF: Page 431
TOP: Bedtime Habits KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. What fear is unique to the preschool period?
a. Water
b. Animals
c. Bodily harm
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d. Death
ANS: C
The fear of bodily harm, particularly the loss of body parts, is unique to this stage.
DIF: Cognitive Level: Knowledge REF: Page 432
TOP: Fear KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. A 4-year-old child tells the nurse she will not eat peas because they are green. Of what is this an example?
a. Egocentrism
b. Artificialism
c. Animism
d. Centering
ANS: D
The tendency to concentrate on a single outstanding characteristic of an object while excluding other features
is known as centering.
DIF: Cognitive Level: Application REF: Page 428
TOP: Centering KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. A 4-year-old child insists he has more money with a nickel than his father has with a dime. What is this
perception, as described in Piagets theory?
a. Egocentrism
b. Artificialism
c. Animism
d. Intuition
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ANS: D
The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside appearance of
objects. A nickel is larger than a dime and therefore more valuable.
DIF: Cognitive Level: Comprehension REF: Page 428
TOP: Cognitive Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. What will children who are unable to express themselves with words often do?
a. Become reclusive and introspective
b. Develop other methods of verbal communication
c. Engage in more creative play
d. Have tantrums and act out
ANS: D
Children with delayed communication skills will frequently have tantrums and act out when they are unable to
make their needs known.
DIF: Cognitive Level: Comprehension REF: Page 428
TOP: Tantrums KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. Which is an example of associative play?
a. Two children playing house, one playing the role of the dad and the other playing the mom
b. Two children playing in a sand box, one building a wall and the other digging a hole
c. Two children playing with sports-associated items, one with a football and the other with a bat
d. Two children playing with a coloring book, one coloring pictures and the other looking at pictures
ANS: A
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Associative play allows the preschoolers to use their enlarged vocabulary in play with other children to carry
on conversations and describe scenarios for each to play.
DIF: Cognitive Level: Analysis REF: Page 431
TOP: Associative Play KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. The nurse is educating a group of preschool parents about the importance of safety. Which statement by a
parent indicates the need for further education?
a. I continue to provide a great deal of indirect supervision for my child.
b. My stairway is always free of clutter.
c. I only leave my child in the car for brief moments.
d. Medications are kept in a locked cabinet.
ANS: C
Children must not play in or around the car or be left alone, even for a brief moment, in the car. Preschool
children still require a good deal of indirect supervision to protect them from dangers that arise from their
immature judgment or social environment. Stairways should be free of clutter and medications kept out of
reach.
DIF: Cognitive Level: Comprehension REF: Page 437
TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23. Parents of a 5-year-old child tell the nurse they are concerned about their childs speech development by
stating, No one can understand him but us. What clinical classification of speech disorder does the nurse
suspect?
a. Global language delay
b. Expressive language delay
c. Language loss
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d. Articulation disorder
ANS: D
When parents are the only people to understand their preschool child, an articulation disorder is suspected. (Se
Table 18-3.)
DIF: Cognitive Level: Application REF: Page 430
TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
24. What does including play in the plan of care for a 5-year-old allow the child to do? (Select all that apply.)
a. Exercise his imagination
b. Assume a role and act it out
c. Offers an emotional outlet
d. Avoid magical thinking
e. Interact with other children
ANS: A, B, C, E
Benefits of play for the preschooler include exercising imagination, assuming a role and acting it out, offering
an emotional outlet, and interaction with other children. Play employs the use of magical thinking.
DIF: Cognitive Level: Knowledge REF: Page 429
OBJ: 10 TOP: Purpose of Play
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. What developmental milestone(s) assist the 5-year-old boy toward developing his sexual identity? (Select
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170
all that apply.)
a. Begins to be less focused on his mother
b. Ignores both parents totally
c. Regresses to a more infantile level
d. Forms a romantic attachment to the mother
e. Identifies with the parent of the same sex
ANS: A, D, E
Children of this age become less focused on the mother as the central person and begin to identify with the
parent of the same sex, forming a romantic attachment to the parent of the opposite sex. This little boy might
say, Im going to marry my mother. A little girl might say, Im going to marry my daddy.
DIF: Cognitive Level: Application REF: Page 432
OBJ: 2 TOP: Romantic Attachment to Parent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. Which bedtime preparation rituals are the most appropriate for the nurse to suggest? (Select all that apply.)
a. Telling a story
b. Placing a favorite toy in bed
c. Placing a glass of water at the bedside
d. Turning on a night light
e. Playing energetically
ANS: A, B, C, D
All options are soothing bedtime rituals except energetic playing, which would be stimulating and
counterproductive to sleep.
DIF: Cognitive Level: Comprehension REF: Page 431
TOP: Bedtime Habits KEY: Nursing Process S
NtU
epR:SIIm
NpGlT
em
B.eCnO
taM
tion
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. The nurse points out what advantage(s) of a nursery school or preschool experience? (Select all that apply.)
a. Increasing self-confidence
b. Fostering group cooperation
c. Detecting adjustment problems
d. Attainment of toilet training skills
e. Playing experiences with other children
ANS: A, B, C, E
Nursery school increases self-confidence, group cooperation, social skills, and cooperative play. Objective
observations by a nursery school instructor can detect early adjustment problems. The child is usually toilet
trained prior to the start of preschool.
DIF: Cognitive Level: Comprehension REF: Page 436
TOP: Advantages of Nursery School KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. Which major developmental tasks will the nurse expect a child to accomplish by the end of the preschool
years? (Select all that apply.)
a. Development of parallel play
b. Acceptance of separation
c. Increased communication skills
d. Consistent appetite
e. Control of bodily functions
ANS: B, C, E
The major tasks of the preschool child include preparation to enter school, development of a cooperative type
of play, control of body functions, acceptance of separation, and increase in communication skills, memory,
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and attention span. Appetite remains inconsistent.
DIF: Cognitive Level: Comprehension REF: Page 427
TOP: Major Developmental Tasks. KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
29. When planning an activity for a 3-year-old, the nurse bases the plan on the average attention span of
minutes.
ANS:
15
The average attention span of the preschooler is about 15 minutes.
DIF: Cognitive Level: Comprehension REF: Page 429
OBJ: 3 TOP: Attention Span of Preschooler
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30. Play that is designed to retrain muscles or improve eye-hand coordination is considered
play.
ANS:
therapeutic
Therapeutic play, whether at home or in a clinic or rehab center, is designed to retrain muscles, strengthen
muscles, or improve eye-hand coordination
DIF: Cognitive Level: Knowledge REF: PageN4U
39RSINGTB.COM
TOP: Therapeutic Play KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. The gradual transfer of behavioral control from the parent to the child is accomplished through
.
ANS:
discipline
Through discipline the parent gradually gives up behavior self-control to the child.
DIF: Cognitive Level: Comprehension REF: Page 433
TOP: Discipline KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32.
is a preschoolers idea that the world and all of its contents are created by people.
ANS:
Artificialism
Artificialism is the belief that all things in the world have been created by people.
DIF: Cognitive Level: Knowledge REF: Page 428
TOP: Artificialism KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33.
is seen in the play of children who pretend that an empty box is a fort;
they create a mental image to stand for something that is not there.
ANS:
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Symbolic functioning
Symbolic functioning is seen in the play of children who pretend that an empty box is a fort; they create a
mental image to stand for something that is not there.
DIF: Cognitive Level: Knowledge REF: Page 428
TOP: Symbolic Functioning KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
34. Put the stages of separation anxiety in order from first to last. Put a comma and space between each answer
choice (a, b, c, d, etc.)
a. Detachment
b. Regression
c. Despair
d. Protest
ANS:
D, C, A, B
The preschool child may feel abandoned by the parents and continues to be subject to separation anxiety.
Separation anxiety is manifested by the stages of protest, despair, detachment, and regression.
DIF: Cognitive Level: Comprehension REF: Page 439
TOP: Separation Anxiety KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 19: The School-Age Child
MULTIPLE CHOICE
1. The nurse is assessing a school-age child. What will the nurse expect in regard to physical development of
this child?
a. Growth of 3 to 6 inches per year
b. Gain of 5 to 7 pounds per year
c. Increase of head circumference by 1 inch per year
d. A visual acuity of 20/20 by 9 years of age
ANS: B
During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds.
DIF: Cognitive Level: Knowledge REF: Page 443
TOP: Physical Growth KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. What should the nurse keep in mind when planning to teach a class on nutrition to fourth-grade students?
a. School-age children can concentrate on only one aspect of a situation.
b. School-age children can think abstractly.
c. School-age children are egocentric in their thinking.
d. School-age children think logically and concretely.
ANS: D
Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and
an understanding of cause and effect.
DIF: Cognitive Level: Comprehension REF: Page 442
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OBJ: 3 TOP: Cognitive Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. What type of relationships are the preferred social interactions for the school-age child?
a. Heterosexual interest groups
b. Association with one best friend
c. Rigidly organized groups with complex rules
d. Same-sex peer groups
ANS: D
The preferred social interaction of the school-age child is in same-sex peer groups or cliques.
DIF: Cognitive Level: Analysis REF: Page 443
TOP: Social DevelopmentPlay KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse is advising parents of a 10-year-old boy about the most developmentally supportive experiences
for their son. What is the best experience for this child according to Eriksons theory?
a. Constant variety of activities
b. Successful performance in Little League
c. Feeling healthy and strong
d. Having a girlfriend
ANS: B
The child who is successful in activities will feel positively about himself or herself.
DIF: Cognitive Level: Analysis REF: Page 443
TOP: Psychosocial Development KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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5. The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent
nightmares. What is the nurses most helpful response to explain nightmares?
a. They are a normal extension of the childs fear of mutilation.
b. They are an abnormal response to repressed feelings.
c. They are a common result of latent sexuality.
d. They are a side effect of overactivity and stimulation.
ANS: A
The nightmares experienced by an 8-year-old are an extension of their characteristic fear of mutilation.
DIF: Cognitive Level: Comprehension REF: Page 452
OBJ: 3 TOP: Eight-Year-Old
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. What is the best suggestion by the nurse for an appropriate toy for a hospitalized 6-year-old boy?
a. Handheld video game
b. MP3 player
c. Adventure book
d. Jigsaw puzzle
ANS: A
The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the handheld
video game will offer nonaggressive competition.
DIF: Cognitive Level: Analysis REF: Page 452
OBJ: 3 TOP: Six-Year-Old KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. The nurse discusses preparation for school w
ithRSthIN
eG
paTrB
en.CtsOoM
f a 6-year-old girl who will soon be starting
NU
first grade. What statement by the girls father leads the nurse to determine that the parents understood the
information?
a. We should put a stop to her thumb-sucking.
b. Well have a talk about what school is like.
c. We will let her walk to the bus stop by herself.
d. Well have her meet some children who will be in her class.
ANS: D
To prepare a child for school, parents can arrange for the child to meet other children who will be entering
school with her.
DIF: Cognitive Level: Application REF: Page 446
OBJ: 4 TOP: Parental Guidance for Starting School
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. A 9-year-old boy is often cranky and irritable, and his school performance has declined. What is the most
probable factor causing this behavior?
a. He sleeps only 6 to 7 hours a night.
b. He eats eggs every day.
c. He has a new dog.
d. He plays about 1 to 3 hours each evening.
ANS: A
The 9-year-old child requires about 10 hours of sleep per night.
DIF: Cognitive Level: Application REF: Page 449
TOP: Nine-Year-Old KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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9. A parent asked the nurse, At what age are children capable of assuming more responsibility for personal
belongings? What is the nurses best response based on knowledge of growth and development?
a. 6 years
b. 7 years
c. 9 years
d. 12 years
ANS: C
The 9-year-old is dependable and assumes more responsibility for personal belongings.
DIF: Cognitive Level: Comprehension REF: Page 448
TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. The school nurse is preserving a tooth that was knocked out on the school playground. What will the nurse
be especially careful to do?
a. Wrap the tooth loosely in a clean cloth.
b. Rinse the tooth with alcohol.
c. Handle the tooth only by the crown.
d. Place the tooth in a warm environment.
ANS: C
When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage
to the root and placed in milk until the child can be examined by a dentist.
DIF: Cognitive Level: Application REF: Page 447
OBJ: 7 TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. A parent states, My 7-year-old really wantN
sU
a RdSoIgN. G
HTisB1.C
0O
-yM
ear-old brother has allergies to animal dander. I
dont know what to do. What type of pet should the nurse suggest as the best choice?
a. A small breed of dog because the large dogs produce more allergens
b. An older unneutered dog that produces fewer allergens than a younger one
c. A cat because it requires less care and is less allergenic
d. A poodle, which does not shed, making it a good choice for people with allergies
ANS: D
The poodle does not have a shed cycle and so it may be the least offensive pet for the allergic child.
DIF: Cognitive Level: Analysis REF: Page 456
TOP: Pet Ownership KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in the school
band, and I take tennis lessons. What does the nurse know these activities will help this child develop?
a. Initiative
b. Industry
c. Identity
d. Intimacy
ANS: B
The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities
facilitates the childs sense of industry.
DIF: Cognitive Level: Application REF: Page 442
TOP: Psychosocial Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. A mother reports that she has a new job and her 12-year-old child is home alone for a time after school.
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Which statement made by the parent alerts the nurse to a potentially unsafe situation for this child?
a. I told him that he could invite a few friends after school.
b. I put a list of emergency numbers next to the telephone.
c. Last week we made a first aid kit together.
d. There is a neighbor available in case of an emergency.
ANS: A
Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to
be home alone in an unsupervised environment is an unsafe situation.
DIF: Cognitive Level: Application REF: Page 447
TOP: Latchkey Children KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. A mother is concerned because her 9-year-old boy has developed the habit of twitching his eyes and
flipping his hair while communicating with anyone. What is the best nursing response to this parent?
a. This may indicate that he needs eyeglasses.
b. Children sometimes do these things for attention.
c. This behavior suggests low self-esteem.
d. Tics appear when a child is under stress.
ANS: D
The child cannot help such actions and should not be scolded for them because they are mainly a result of
tension.
DIF: Cognitive Level: Application REF: Page 449
TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. A seventh-grade girl tells the school nurseNthUaRt ShIeNr G
arTtBte.C
acOhM
er, a woman, is her hero. What is the most
appropriate interpretation of the girls comment?
a. The student may be exploring her career options.
b. The comment is cause for concern about sexual abuse.
c. The child may have difficulty interacting with her peers.
d. Hero worship is a normal phenomenon.
ANS: D
School-age children tend to admire their teachers and adult companions. For the 11- to 12-year-old, hero
worship is a normal phenomenon.
DIF: Cognitive Level: Comprehension REF: Page 454
OBJ: 3 TOP: Social Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. Which stage of cognitive development is a 9-year-old child in according to Piaget?
a. Formal operations
b. Preoperational
c. Concrete operations
d. Sensorimotor
ANS: C
School-age children are in the concrete operations stage of cognitive development.
DIF: Cognitive Level: Knowledge REF: Page 442
TOP: Cognitive Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. What statement by an 11-year-old leads the nurse to determine he has moved from the mind set of
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egocentrism?
a. I am a member of the best Cub Scout group in the world.
b. I must do my homework before I can play.
c. My dad can do anything!
d. Im sorry. I bet that hurt your feelings.
ANS: D
The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mindset.
DIF: Cognitive Level: Analysis REF: Page 452
OBJ: 3 TOP: Increasing Understanding
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. A school-age child becomes frustrated with a school assignment and says, I cant do this! What is the most
developmentally supportive response from the parent?
a. Ask, What is it that is so difficult?
b. Allow the child to quit the effort.
c. Call in older siblings to help.
d. Finish the project for them.
ANS: A
Helping the child focus on the problem that is keeping him from mastery can limit frustration. Quitting or
having someone else finish is detrimental to the development of industry.
DIF: Cognitive Level: Analysis REF: Page 442
TOP: Industry KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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19. What is best for the nurse to suggest to the parents of an overweight 9-year-old to help prevent obesity?
a. Use whole milk as a between-meal snack because it is more filling than skim milk.
b. Feed the child before family meal times to monitor intake more closely.
c. Encourage the child to engage in physical activity for at least an hour a day.
d. Remove all sweets and junk food from the house.
ANS: C
Regular physical activity reduces weight.
DIF: Cognitive Level: Comprehension REF: Page 451
OBJ: 7 TOP: Prevention of Obesity
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. A parent confides in the school nurse that her 8-year-old twins argue and bicker constantly. What is the
best response by the nurse?
a. Express alarm at the constant aggression.
b. Voice concern and investigate referral for counseling.
c. Inquire about what punitive action the parents have taken to stop it.
d. Offer reassurance that such behavior is normal for 8-year-olds.
ANS: D
Argumentative and competitive behavior is normal in 8-year-olds.
DIF: Cognitive Level: Application REF: Page 448
TOP: Argumentative Behavior KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. The school nurse is planning sex education classes for school-age children. What should the nurse be sure
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to do?
a. Use simple terms.
b. Avoid slang or street words and concepts.
c. Keep topics on biological aspects of sexual development.
d. Limit questions to keep content clear.
ANS: A
Using simple terms is essential but slang and street terms need to be clarified. Apply age-specific information
across broad aspects of biological, social, and current attitudes.
DIF: Cognitive Level: Application REF: Page 444
OBJ: 7 TOP: Sex Education
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. Parents ask the pediatric nurse how school life might influence their growing child. What area of
development will the nurse indicate that school affects the least?
a. Moral development
b. Social development
c. Physical development
d. Cognitive development
ANS: C
Physical development is the least affected by school life. Moral development occurs as they have experience
with, and understand, rules and fairness in the school setting. Schools have a profound influence on the
socialization of children, who bring to school what they have learned and experienced in the home. Success in
school requires an integration of cognitive, receptive, and expressive (language) skills.
DIF: Cognitive Level: Application REF: Page 445
TOP: Impact of School Life KEY: Nursing PrN
ocUeRssSISNteGpT: BP.lCanOnM
ing
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
23. What basic feeling words should the nurse use in attempting to help a 7-year-old girl express her feelings
about being in a new school? (Select all that apply.)
a. Mad
b. Glad
c. Sad
d. Scared
e. Jealous
ANS: A, B, C, D
The words mad, glad, sad, and scared are basic feeling words that can prompt a young child to better express
his or her feelings.
DIF: Cognitive Level: Application REF: Page 451
OBJ: 3 TOP: Expression of Feelings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
24. The school nurse is preparing an educational program for new teachers regarding school-age children.
What information is accurate for the nurse to include? (Select all that apply.)
a. Participation in group activity increases
b. Egocentricity prevails
c. Thinking is logical
d. Preference is toward family interaction
e. Understand cause and effect
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ANS: A, C, E
Piaget refers to the thought processes of the school age period as concrete operations.
Concrete operations involve logical thinking and an understanding of cause and effect.
The egocentric view of the preschool child is replaced by the ability to understand the point of view of another
person. Between 6 and 12 years of age, children prefer friends of their own sex and usually prefer the company
of their friends to that of their brothers and sisters.
DIF: Cognitive Level: Comprehension REF: Page 442
TOP: Personality Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. The pediatric nurse is presenting school-age children with information on safety issues to follow when
going home alone. What guidelines should they be educated to follow? (Select all that apply.)
a. Ask for identification before letting someone in the house.
b. Never accept rides with strangers.
c. Keep doors locked.
d. Do not enter house if door is ajar.
e. Walk to and from school with friends.
ANS: B, C, D, E
Strangers should never be allowed in the house. Children should be instructed never to accept rides with
strangers, to keep doors locked, not to enter the house if the door is ajar, and to walk to and from school with
friends.
DIF: Cognitive Level: Comprehension REF: Page 447
OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26. A 10-year-old child with disabilities is begging her parents for a dog. When at the pediatric clinic, the
parents inquire about possible benefits pet owN
neUrsRhSiIpNm
ide to their child. What benefits of pet
GaTyBp.CroOvM
ownership should the nurse indicate? (Select all that apply.)
a. Decrease the need for physical therapy
b. Lower blood pressure
c. Improve communication
d. Foster trust
e. Ease path to socialization
ANS: B, C, D, E
Studies have documented the positive influence of pet ownership on improving the medical and psychological
outcome after illness or surgery. Disabled children especially benefit from interacting with pets. The
interaction with animals can lower blood pressure and heart rate, reduce loneliness and feelings of isolation,
improve communication, foster trust, and motivate participation in physical therapy. Pets allow the ill child
who feels separated from other people to feel companionship and acceptance. Shy children often find pet
ownership eases the path to socialization with others who initiate contact because of the pet.
DIF: Cognitive Level: Comprehension REF: Page 455
OBJ: 8 TOP: Pet Ownership
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
27. The nurse advises the parents of a 6-year-old to try and ensure at least
child.
ANS:
11
The 6-year-old school-age child needs at least 11 hours of sleep.
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DIF: Cognitive Level: Comprehension REF: Page 448
TOP: Sleep Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. The nurse reminds the parents who are trying to select a dog for their allergic child that the best selection
would be a female dog that is
and
.
ANS:
young, spayed
Young, neutered female dogs produce less allergens.
DIF: Cognitive Level: Comprehension REF: Page 455
OBJ: 8 TOP: Pet Selection for Allergic Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
29. When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse
cautioned the teacher to be alert for symptoms of
that can be carried by the reptiles.
ANS:
Salmonella
Geckos can infect humans with Salmonella.
DIF: Cognitive Level: Comprehension REF: Page 455
OBJ: 8 TOP: Salmonella KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. The pediatric nurse assesses the 9-year-old child who has been diagnosed with diabetes to ensure that he
does not come to believe that his disease is a fN
orUmRSoIfNGTB.COM
.
ANS:
punishment
School-age children may come to believe their illness is a form of punishment for bad behavior or bad
thoughts.
DIF: Cognitive Level: Comprehension REF: Page 443
TOP: Disease as Punishment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The nurse explains that the term
female traits.
refers to a sex role that incorporates both male and
ANS:
androgynous
Sex roles that involve male and female qualities lead to better human functioning.
DIF: Cognitive Level: Knowledge REF: Page 444
TOP: Sex Education KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32. The nurse is aware that by the age of
, the first permanent teeth erupt.
ANS:
6
At the age of 6, the first permanent teeth erupt: the 6-year molars.
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DIF: Cognitive Level: Knowledge REF: Page 443
TOP: Eruption of Permanent Teeth KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. The
maintains that every sex education program should present the
topic from six aspects: biological, social, health, personal adjustment and attitudes, interpersonal associations,
and establishment of values.
ANS: Sexuality Information and Education Council of the United States (SIECUS)
DIF: Cognitive Level: Knowledge REF: Page 444
TOP: Sex Education KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 20: The Adolescent
MULTIPLE CHOICE
1. The nurse is assessing a 13-year-old boy. With what do physical changes in the pubertal male begin?
a. Development of axillary and facial hair
b. Enlargement of penis
c. Enlargement of testicles
d. Pigmentation of the scrotum
ANS: C
In boys, pubertal changes begin with enlargement of the testicles and internal structures.
DIF: Cognitive Level: Knowledge REF: Page 462
OBJ: 4 TOP: Physical Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. A 13-year-old boy states, The girls in my class tower over me. What would be the nurses most informative
response?
a. It may seem that way because girls have a growth spurt 2 years earlier than boys.
b. Perhaps your parents are not exceptionally tall.
c. Boys usually experience a growth spurt 1 year earlier than girls.
d. You may feel short, but you are actually average height for your age.
ANS: A
Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for
boys.
DIF: Cognitive Level: Application REF: PageN4U6R
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OBJ: 4 TOP: Physical Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. A parent comments that her adolescent daughter seems to be daydreaming a lot. What does the nurse
understand this behavior to indicate regarding their daughter?
a. She is bored.
b. She is not getting enough rest.
c. She is trying to block out stress and anxiety.
d. She is mentally preparing for real situations.
ANS: D
Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations.
This helps them to prepare for and cope with interactions with others.
DIF: Cognitive Level: Comprehension REF: Page 468
TOP: DevelopmentDaydreams KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse is planning a safety program for high school students. To what will the nurse relay that most
accidental deaths in adolescence are related?
a. Firearms
b. Automobiles
c. Drowning
d. Diving injuries
ANS: B
The chief safety hazard for the adolescent is automobiles.
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DIF: Cognitive Level: Knowledge REF: Page 473
TOP: Safety KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response represents an
effective problem-solving approach for his parents?
a. Your studies are too important for you to have a part-time job.
b. When we went to high school, academics were the adolescents priority.
c. We want you to put your earnings in a savings account.
d. How do you think you will manage your school work and a job?
ANS: D
An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring
alternatives.
DIF: Cognitive Level: Application REF: Page 471
OBJ: 5 TOP: Parenting KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. The nurse is planning care of an adolescent. What psychosocial task does the nurse understand is important
for the adolescent to develop?
a. A sense of initiative
b. A sense of industry
c. A sense of identity
d. A sense of involvement
ANS: C
Psychosocial milestones that must be accomplished during adolescence include the five Isimage of self,
identity, independence, interpersonal relationships, and intellectual maturity.
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DIF: Cognitive Level: Knowledge REF: Page 459
OBJ: 5 TOP: Psychosocial Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. A 13-year-old girl tells the school nurse that she is getting fat, especially in her hips and legs. What
understanding by the nurse would best guide the response?
a. Many adolescents are unaware of proper nutrition.
b. Adolescents of this age become less active and should eat fewer calories.
c. Puberty is often preceded by fat deposits in these areas.
d. As soon as menarche occurs, she will lose this excess weight.
ANS: C
Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and
breasts, causing them to enlarge.
DIF: Cognitive Level: Application REF: Page 464
OBJ: 4 TOP: Physical Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8. The school nurse is planning a program for girls about the physical changes of puberty. Toward what age
girl should this program be directed?
a. 10 years
b. 12 years
c. 14 years
d. 16 years
ANS: A
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Because puberty can occur in girls as early as age 10 years, instruction must be given by that age.
DIF: Cognitive Level: Comprehension REF: Page 460
TOP: Physical Development KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. What statement made by a parent indicates an understanding about helping a 13-year-old manage his
allowance?
a. I set amounts he can earn for particular chores.
b. I give him a certain amount of money for each day.
c. I put money into his bank account each month.
d. I told him to ask me when he needs money.
ANS: A
If money is simply handed out as requested, it is difficult to develop responsibility for finances and money
management. The older adolescent is able to get a job. The younger adolescent can earn money by doing
particular chores.
DIF: Cognitive Level: Comprehension REF: Page 467
OBJ: 8 TOP: DevelopmentResponsibility
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10. What can the nurse suggests as a good dietary source of zinc for an adolescent who is a vegetarian?
a. Green, leafy vegetables
b. Citrus fruits
c. Nuts
d. Enriched breads
ANS: C
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Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts,
legumes, and wheat germ.
DIF: Cognitive Level: Comprehension REF: Page 472
TOP: Nutrition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. An adolescents parent comments, My son seems so preoccupied with his appearance these days. Is this
normal? What is the nurses best response?
a. It is his attempt to express his individualism.
b. His preoccupation with his looks is quite normal.
c. He is probably troubled with his physical changes.
d. This shows that he has a positive self-image.
ANS: B
Preoccupation with self-image is normal and accounts for the constant primping of adolescents.
DIF: Cognitive Level: Application REF: Page 462
OBJ: 14 TOP: Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12. What foods would be a healthy choice for an adolescent who just finished playing in a strenuous sports
game?
a. A cheeseburger and soda
b. A hot fudge sundae
c. Two sausage and egg breakfast sandwiches and orange juice
d. A bagel and skim milk
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ANS: D
A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow release of
carbohydrates to the muscles.
DIF: Cognitive Level: Comprehension REF: Page 472
TOP: Nutrition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. When planning to answer a 16-year-old girls questions about menstruation, the nurse must consider
cognitive development. What is developed during adolescence according to Piaget?
a. The ability to view a situation from multiple perspectives
b. The ability to focus more on the past than present situations
c. The ability to exercise concrete reasoning
d. The ability to consider hypothetical situations
ANS: D
According to Piaget, in the formal operations stage adolescents have the ability to think abstractly.
DIF: Cognitive Level: Comprehension REF: Page 460
OBJ: 2 TOP: Cognitive Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14. A girl tells the nurse that she and her best friend belong to the popular clique. She states, I love Katy Perry,
and I want to be a singer. The nurse recognizes the girls statement as characteristic of what time period?
a. Early adolescence
b. Middle adolescence
c. Late adolescence
d. The entire adolescent period
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ANS: A
Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent.
DIF: Cognitive Level: Comprehension REF: Page 462
OBJ: 10 TOP: Social Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15. The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant do
anything without checking with his friends first. My opinion doesnt count anymore. What knowledge in regard
to this behavior would the nurse formulate as a response?
a. It is unusual for adolescent boys.
b. It is often more apparent in boys than girls.
c. It is a normal phenomenon during adolescence.
d. It is suggestive of feelings of low self-worth.
ANS: C
Parents may need help understanding that the adolescents exaggerated conformity is necessary for moving
away from dependence and obtaining approval from persons outside the nuclear family.
DIF: Cognitive Level: Comprehension REF: Page 466
OBJ: 10 TOP: Peer Relationships
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16. What does an adolescents peer group serve as related to development?
a. Social outlet
b. Association to blur personal identity
c. Platform for group think
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d. Initial separation from family
ANS: D
Being a member of a peer group and communicating with and seeking approval from this group are hallmarks
of the first separation from the family.
DIF: Cognitive Level: Comprehension REF: Page 462
OBJ: 10 TOP: Peer Groups KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17. At what stage is the adolescent considered to be,according to Freuds theory?
a. Conceptual
b. Genital
c. Glandular
d. Pubertal
ANS: B
Freud describes the adolescent period as genital.
DIF: Cognitive Level: Knowledge REF: Page 460
OBJ: 2 TOP: Freud KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a score of 2 for
an adolescent patient. How would the nurse interpret this score?
a. Nonindicative of potential substance abuse
b. Normal experimentation of the adolescent
c. Need to schedule another PACE interview in 3 months
d. Indication for referral for counseling
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ANS: D
The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling
about substance abuse.
DIF: Cognitive Level: Analysis REF: Page 474
OBJ: 14 TOP: PACE Interview
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. What does adolescent acne result from?
a. Ineffective sweat glands
b. Oily skin
c. Inadequate hygiene
d. A poor diet
ANS: B
Adolescent acne is the result of overactive sweat glands and oily skin.
DIF: Cognitive Level: Comprehension REF: Page 460
TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20. The nurse suggests the use of I messages to communicate a parents feeling to an adolescent. What is the
most appropriate example of an I message?
a. I feel frightened when you stay out past your curfew.
b. I am your mother, and I insist that you observe your curfew.
c. I am sick and tired of your staying out late.
d. I expect you to show me proper respect.
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ANS: A
This is the only statement that associates the parents feelings about the adolescent behavior that is not
aggressive or accusatory.
DIF: Cognitive Level: Analysis REF: Page 471
OBJ: 14 TOP: I Statements
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. A 13-year-old girl tells the nurse she is concerned because she has not had her first menstrual period. What
is the best initial response from the nurse?
a. Your hormone levels may be irregular.
b. Could you be pregnant?
c. Age of first menstrual cycle varies.
d. Do not worry about it.
ANS: C
Puberty is easily recognized in girls by the onset of menstruation. The first menstrual period is called the
menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years
or as late as age 15 years.
DIF: Cognitive Level: Application REF: Page 464
TOP: Menstrual Cycle KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. The nurse is documenting the pediatricians assessment of a female patient. When assessing Tanners stages
of breast development there is elevation of papilla only. What stage of development will the nurse document?
a. Stage 1
b. Stage 2
c. Stage 3
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d. Stage 4
ANS: A
According to Tanners Stages of Sexual Maturity, Stage 1 (Preadolescent) is elevation of papilla only.
DIF: Cognitive Level: Application REF: Page 463
OBJ: 7 TOP: Breast Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23. The school nurse is educating high school students about guidelines to be followed when participating in
sports. Which statement by a student alerts the nurse of the need for further information?
a. I will eat carbohydrates before practice.
b. I drink large amounts of fluid when working out.
c. I wear protective gear every time I play sports.
d. I avoid caffeine when participating in sports.
ANS: B
Fluids lost by sweat must be replaced by drinking small amounts of fluid during a workout. Thirst is one guide
for intake. Caffeine and alcohol deplete body water and are to be avoided. Carbohydrates that provide both
energy and other nutrients are best for athletes. Protective gear should be worn by all team players in any
contact sport.
DIF: Cognitive Level: Application REF: Page 472
TOP: Sport Guidelines KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
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24. To what is the restlessness seen in the adolescent considered to be attributed? (Select all that apply.)
a. Drive to be accepted by society as an individual
b. Urge for independence
c. Establishment of a personal identity
d. Intense libido
e. Slowing of body changes
ANS: A, B, C, D
All the options listed are sources of stress to the adolescent and are stimulants to restlessness except option E:
body changes are rapid.
DIF: Cognitive Level: Comprehension REF: Page 459
TOP: Sources of Stress for the Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25. What are the best breakfast choices for the nurse to point out prior to a big exam, to provide high levels of
alertness and increased memory? (Select all that apply.)
a. Pancakes and syrup
b. Coffee and chocolate-covered donuts
c. Bacon and fried eggs
d. Whole grain cereal and yogurt
e. Oatmeal and sliced apples
ANS: D, E
Meals high in protein will break down into norepinephrine and increase alertness. Meals with a high sugar
content result in a soothing sleepy response. Meals high in fats digest slowly and draw blood from the brain
during the lengthy digestive process.
DIF: Cognitive Level: Application REF: PageN4U7R
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TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. The nurse considers what rites of passage valued by the adolescent in American society? (Select all that
apply.)
a. Attaining legal drinking age
b. Selection of a career
c. Religious affiliation
d. Obtaining a drivers license
e. High school graduation
ANS: A, D, E
Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, drivers license,
and matriculation through high school are such signals. Religious affiliation and selection of a career path do
not necessarily signal adulthood.
DIF: Cognitive Level: Comprehension REF: Page 473
OBJ: 9 TOP: Rites of Passage
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27. A mother confides in the school nurse that she witnessed her son kissing another boy. Which concepts
should guide the nurse to base a reply? (Select all that apply.)
a. Homosexual behavior in adolescents is not uncommon.
b. Homosexuality is a mental disorder.
c. Adolescents often desire to explore alternative lifestyles.
d. Homosexual tendencies should be addressed with counseling.
e. Parents should seek a support group for parents of gays.
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ANS: A, C
Adolescents may experiment with an alternate sexual expression as part of their self-discovery. Homosexual
activities are not uncommon in adolescence.
DIF: Cognitive Level: Comprehension REF: Page 469
OBJ: 11 TOP: Homosexuality
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28. The school nurse is discussing challenges of the adolescent years with a group of high school students in
health class. What challenges toward adolescent development will the nurse include?
a. Developing intimacy
b. Maintaining dependence on parents
c. Searching for identity
d. Adjusting to body changes
e. Establishing future goals
ANS: A, C, D, E
Adolescents face the challenges of developing intimacy, searching for identity, adjusting to body changes and
establishing goals for the future. Adolescents are striving for independence from parents.
DIF: Cognitive Level: Comprehension REF: Page 459
OBJ: 3 TOP: Challenges KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
29. The nurse understands that as adolescents strive for individuality, the strongest need of any adolescent in
society is that of
.
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ANS:
conformity
For all of the stress from coming of age as an individual in his own right, the adolescent also has an equal drive
for conformity.
DIF: Cognitive Level: Comprehension REF: Page 460
TOP: Conformity KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30. The nurse knows that an adolescent may find making a career choice difficult because there is less clarity
in roles.
ANS:
gender
The blurring of gender roles in the United Stateswomen holding jobs as engineers, lawyers, and physicians;
and men entering nursing and culinary pursuitshas caused confusion with the selection of a career path.
DIF: Cognitive Level: Comprehension REF: Page 460
TOP: Blurred Gender Roles KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31. The nurse stresses the need for using a sunscreen with a Sun Protection Factor (SPF) of at least
ANS:
15
A sunscreen with an SPF of at least 15 is recommended to block sun rays that cause cancer.
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DIF: Cognitive Level: Knowledge REF: Page 473
TOP: Sunscreen KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32.
is frequently delayed in girls who are involved in activities that require a lean body and a
high level of physical activity.
ANS:
Menarche
Menarche can be delayed in girls who are involved in such activities as dancing, running, gymnastics, or any
activity that requires a lean body.
DIF: Cognitive Level: Comprehension REF: Page 462
TOP: Menarche KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33. The general appearance of the adolescent tends to be awkward, that is, long-legged and gangling; this
growth characteristic is termed
because different body parts mature at different rates.
ANS:
asynchrony
The general appearance of the adolescent tends to be awkward, that is, long-legged and gangling; this growth
characteristic is termed asynchrony because different body parts mature at different rates.
DIF: Cognitive Level: Knowledge REF: Page 460
TOP: Physical Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 21: The Childs Experience of Hospitalization
MULTIPLE CHOICE
1. Which child would have the most difficulty in coping with separation from parents because of
hospitalization?
a. 3-month-old child
b. 16-month-old child
c. 4-year-old child
d. 7-year-old child
ANS: B
Separation anxiety occurs after age 6 months and is most pronounced in the toddler.
DIF: Cognitive Level: Comprehension REF: Page 481
OBJ: 3 TOP: Separation Anxiety
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. What
does this behavior suggest?
a. The toddler feels abandoned by his mother.
b. The child still has not adjusted to his hospitalization.
c. The child is not separated from his mother often.
d. There is a poor mother-child bond.
ANS: A
Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious.
DIF: Cognitive Level: Analysis REF: Page 48N
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OBJ: 3 TOP: Separation Anxiety
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. Which statement best corresponds to a preschoolers understanding of hospitalization?
a. A germ made me get sick.
b. I got sick because I was mad at my brother.
c. My tonsils are sick and they have to come out.
d. I have a cast because I broke my leg.
ANS: B
The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his or her part.
DIF: Cognitive Level: Application REF: Page 491
TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
4. The parents of a hospitalized toddler are upset because she seems more interested in her toys when they
come to visit her. In which stage of separation anxiety is the toddler?
a. Protest
b. Despair
c. Denial
d. Attachment
ANS: C
In the stage of denial or detachment, the child appears to deny the need for the parents and becomes
uninterested in their visits.
DIF: Cognitive Level: Comprehension REF: Page 481
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OBJ: 3 TOP: Separation Anxiety
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
5. The nurse must make a room assignment for a 16-year-old with cystic fibrosis. Which roommate would be
the most appropriate for this patient?
a. A 4-year-old child who had an appendectomy
b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis
c. A 15-year-old with type 1 diabetes mellitus
d. To assign the adolescent to a private room
ANS: C
Adolescents usually do better in rooms with one or more roommates than in single rooms. The adolescent
would do best with a roommate who is closest to his or her age and also lives with a chronic illness.
DIF: Cognitive Level: Application REF: Page 493
TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling.
What understanding would assist the nurse most in formulating a response?
a. Preschool children can be disruptive in the hospital environment.
b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided.
c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of
microorganisms.
d. The preschooler needs to visit his infant sister to reassure himself that she is all right.
ANS: D
Siblings are affected by a childs hospitalization. Their ability to cope is influenced by their age, experience,
and intactness of the family.
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DIF: Cognitive Level: Application REF: Page 487
TOP: SiblingsParents Reaction to Hospitalization
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
7. A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his
favorite bottle. What is the most likely reason for this behavior?
a. He is dealing with the anxiety of hospitalization by regressing.
b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital.
c. He is attempting to refocus the attention of the adults around him to avoid further painful procedures.
d. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they
have mastered them.
ANS: A
Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of
their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.
DIF: Cognitive Level: Comprehension REF: Page 484
OBJ: 1 TOP: Regression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
8. A nurse encourages a school-age child to draw a picture after a painful procedure. What is the best rationale
for this nursing intervention?
a. Attempting to re-establish rapport
b. Providing a way for the child to express his feelings
c. Encouraging quiet play
d. Distracting the child from thinking about the pain
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ANS: B
After treatments, the nurse should encourage children to draw and talk about their drawings or to act out their
feelings through puppet play.
DIF: Cognitive Level: Comprehension REF: Page 492
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
9. What is the best suggestion by the nurse when parents ask, When is the best time to begin to prepare a 5year-old for surgery and hospitalization?
a. As soon as the surgery is scheduled
b. About 2 weeks before surgery
c. About 4 days before surgery
d. On the night before admission to the hospital
ANS: C
Parents should prepare children for procedures and hospitalization a few days in advance.
DIF: Cognitive Level: Application REF: Page 487
TOP: The Nurses Role in Hospital AdmissionPreparing the Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
10. The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM. The next
morning, the child asks the nurse, When is my mommy coming? What is the nurses best response?
a. Your mommy will be here around noon.
b. Your mommy will be here when you have lunch.
c. Mommy will be here very soon.
d. Your mommy is coming in 4 hours.
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ANS: B
The toddler and preschooler do not understand time yet. They understand time relationships through activities
in their experience, such as naptime and mealtimes.
DIF: Cognitive Level: Application REF: Page 489
OBJ: 10 TOP: The Hospitalized Toddler/Preschooler
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
11. A 13-year-old girl has been hospitalized for the past week. When discussing the girls feelings about her
illness, what would the nurse expect the girl to express as her biggest concern?
a. Invasive procedures
b. Loss of control
c. Appearance
d. Separation from her boyfriend
ANS: C
Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.
DIF: Cognitive Level: Comprehension REF: Page 492
TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
12. The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things the
nurse does for her child. What is the nurses most appropriate response to this mother?
a. Would you like to do all of your childs care?
b. Im doing the very best job that I can with your child.
c. Why dont you go have a cup of coffee? You are going to be exhausted if you dont take a break.
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d. Id love for you to share with me some of the special things you do for your child.
ANS: D
The person who cares daily for the child with a chronic illness can provide information that will best guarantee
continuity of care between the home and the hospital.
DIF: Cognitive Level: Application REF: Page 486
OBJ: 5 TOP: The Parents Reaction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
13. The mother of a hospitalized toddler states, He cries when I visit. Maybe I should just stay away. What is
the nurses best response?
a. Perhaps you are right. He only gets upset when you have to leave.
b. It is important that you are here. This is a common reaction in children when they are separated from their
parents.
c. It might be easier for your child if you would stay with him, but this decision is up to you.
d. We take good care of him and he seems fine when you are not here.
ANS: B
During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and
depressed. The child will revert to protest when the parent arrives for a visit.
DIF: Cognitive Level: Application REF: Page 481
OBJ: 3 TOP: Separation Anxiety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
14. What should the nurse, preparing to collect an admission history from parents who have recently emigrated
from Russia, keep in mind?
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a. Eye-to-eye contact is considered disrespectful.
b. Touching the childs head means the nurse is superior.
c. Smiling is inappropriate in a serious situation.
d. Staring is a sign of the nurses rudeness.
ANS: C
In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.
DIF: Cognitive Level: Comprehension REF: Page 486
TOP: Fostering Intercultural Communication
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
15. Which nursing action would facilitate rapport with a child and the childs parents during the admission
process?
a. Direct the parents to undress the child.
b. Answer questions in a calm and matter-of-fact way.
c. Perform assessments and ask questions as quickly as possible.
d. Express concern about the seriousness of the childs condition.
ANS: B
The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of the childs
condition.
DIF: Cognitive Level: Application REF: Page 487
OBJ: 5 TOP: Nurses Role in Hospital Admission
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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16. When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents are not
available, and the child is crying loudly. Which technique is most appropriate to alleviate the childs distress?
a. Rock the child gently to sleep.
b. Play with the child using pop-up toys.
c. Role play with the child to act out her feelings.
d. Ask the child to draw a picture about her feelings.
ANS: B
Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help
reduce anxiety and pain.
DIF: Cognitive Level: Application REF: Page 490
TOP: The Hospitalized Toddler KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
17. A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this
is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding?
a. Loss of control
b. Restricted mobility
c. Unfamiliar routines
d. Invasive procedures
ANS: D
The preschool-age child is afraid of bodily harm, particularly invasive procedures.
DIF: Cognitive Level: Comprehension REF: Page 491
TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
18. What statement by the parent of a hospitalN
izU
edRStoIN
ddGleTrBl.eCaO
dsMthe nurse to determine the parent understands a
hospitalized toddlers need for transitional objects?
a. This stuffed animal makes him feel secure.
b. He insisted on bringing this dirty old blanket with him.
c. Im going to buy him a big stuffed animal from the gift shop.
d. Id like to get him some toys from the playroom.
ANS: A
The use of a transitional object such as a blanket or a favorite toy promotes security.
DIF: Cognitive Level: Application REF: Page 490
TOP: The Hospitalized Toddler KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
19. An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur.
What does the nurse realize immobilization in this age-group can generate feelings of in planning care of this
child?
a. Loss of control
b. Altered body image
c. Shame and guilt
d. Fear of bodily harm
ANS: A
Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of control and loss of
security.
DIF: Cognitive Level: Application REF: Page 492
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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20. The nurse explains to the parents of a hospitalized child that their child will receive fentanyl for an
upcoming procedure. What advantage of fentanyl will the nurse explain?
a. It is specifically designed for children.
b. It has a rapid onset.
c. It is nonaddicting.
d. It has a long duration.
ANS: B
Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.
DIF: Cognitive Level: Knowledge REF: Page 484
TOP: Fentanyl KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
21. The nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child.
What is this document?
a. Clinical pathway
b. Comprehensive nursing care plan
c. Holistic care approach
d. Incorporated cost analysis
ANS: A
This document is the clinical pathway, which is a broad outline of interdisciplinary plan of care with specific
timelines.
DIF: Cognitive Level: Comprehension REF: Page 488
TOP: Clinical Pathway KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
22. The anxious parent asks if there is a dangeNr U
ofRhSeIN
r 2G-TyB
ea.C
r-O
olM
d child becoming addicted to the opioid pain
reliever. What is the nurses most helpful response?
a. Although this drug is addictive, the doctor monitors the dose very carefully.
b. Dont worry. Addicted children are very easy to wean off the drug.
c. Addiction is rare in children when opiates are given for pain.
d. Addictive behaviors are easy to assess. The drug will be stopped if that happens.
ANS: C
Addiction is rare in children.
DIF: Cognitive Level: Comprehension REF: Page 484
TOP: Pain Relief KEY: Nursing Process Step: Intervention
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23. The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is
appropriate for the nurse to implement?
a. Involve the parents.
b. Provide a simple explanation to the child.
c. Let the child examine the equipment.
d. Suggest coping techniques.
ANS: A
It is appropriate to involve the parents when performing a procedure on an infant. Providng a simple
explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate
interventions for an infant.
DIF: Cognitive Level: Application REF: Page 480
OBJ: 7 TOP: Age-Appropriate Interventions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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24. The pediatric nurse is caring for child that weighs 15 kilograms and calls the physician for an order for
Acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates
ordering?
a. 100 mg
b. 150 mg
c. 225 mg
d. 250 mg
ANS: C
Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children. The
maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours.
DIF: Cognitive Level: Analysis REF: Page 484
TOP: Age-Appropriate Interventions KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
25. What will the nurse include when documenting the discharge of a pediatric patient? (Select all that apply.)
a. Time of discharge
b. Adult(s) accompanying the child and the relationship to the child
c. Condition of the child
d. Method of transportation
e. Instructions that were given to physician
ANS: A, B, C, D
Information that should be included in the discharge note include time of discharge, adults accompanying the
child and relationship to child, condition of the child, and method of transportation. It should also be
documented that instructions were given to parents.
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DIF: Cognitive Level: Application REF: Page 494
OBJ: 12 TOP: Discharge Documentation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
26. The nurse suggests to parents that they use the outpatient surgical center for their childs upcoming surgery.
What advantage(s) does this type of facility have to offer? (Select all that apply.)
a. Lower cost
b. Less incidence of health careassociated infections
c. Reduction of parent-child separation
d. Ample time for recuperation at the facility
e. Decreased emotional impact of illness
ANS: A, B, C, E
All options listed are advantages of outpatient services with the exception of recuperating at the facility.
DIF: Cognitive Level: Comprehension REF: Page 479
OBJ: 2 TOP: Outpatient Facilities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
27. What are the basic fears of a young child being hospitalized? (Select all that apply.)
a. Separation
b. Permanent scarring
c. Pain
d. Cost
e. Body intrusion
ANS: A, C, E
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Small children all share the same basic fears relative to hospitalization, which are separation from family, pain,
and body intrusion or mutilation.
DIF: Cognitive Level: Comprehension REF: Page 481
TOP: Basic Fear KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
28. What information will the nurse include when taking a developmental history? (Select all that apply.)
a. Previous experience with hospitalization
b. Cultural needs
c. History of illness
d. Allergies
e. Childs nickname
ANS: A, B, E
The developmental history has information about the child and the childs developmental and cultural needs and
personal preferences. The information relative to history of illness or allergies would be covered in the medical
history.
DIF: Cognitive Level: Application REF: Page 488
TOP: Developmental History KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
29. The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate for
the nurse to implement? (Select all that apply.)
a. Model desired behavior.
b. Instruct patient not to yell.
c. Use distractions.
d. Explain the procedure in detail.
e. Encourage the child to ask questions.
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ANS: A, C
Whenever possible the parent should be involved in the preparation for and initiation of a treatment or
procedure, and the child should be prepared according to his or her developmental level. For a toddler, model
the behavior desired (i.e., opening the mouth), tell the child it is okay to yell if the treatment or procedure is
uncomfortable, and use distractions. Explaining the procedure in detail and encouraging questions are
appropriate interventions for an older child.
DIF: Cognitive Level: Application REF: Page 490
TOP: Promoting a Positive Experience KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
30. Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they
expect to see when visiting the pediatric unit? (Select all that apply.)
a. Nurses wearing all white
b. Formal atmosphere
c. Availability of a playroom
d. Dim lighting
e. Colored bedding
ANS: C, E
The childrens hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is
designed to meet the needs of children and their parents. A cheerful, casual atmosphere helps to bridge the gap
between home and hospital and is in keeping with the childs emotional, developmental, and physical needs.
Nurses wear colorful uniforms, and colored bedspreads and wagons or strollers for transportation provide a
more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for the
child, soundproof ceilings, and color schemes with eye appeal. Most pediatric departments include a playroom.
DIF: Cognitive Level: Knowledge REF: Page 480
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OBJ: 2 TOP: Health Care Delivery Settings/Pediatric Unit
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
COMPLETION
31. When the preschooler who is hospitalized for surgery to correct a poorly healed fracture says, My doctor is
going to unscrew my bent arm and screw on a new one, the nurse should
this
misconception.
ANS:
correct
All misconceptions that a youngster has about procedures should be corrected.
DIF: Cognitive Level: Knowledge REF: Page 491
TOP: Misconceptions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
32. A(n)
is a person under the age of 18 who can legally sign for consent
for medical treatment for themselves or their children.
ANS:
emancipated minor
A person under the age of 18 who is no longer under the care of his parents authority or a married minor or
minors in the military are considered emancipated minors who are accorded the rights of an adult.
DIF: Cognitive Level: Knowledge REF: Page 493
TOP: Emancipated Minor KEY: Nursing Process Step: N/A
NeUnR
MSC: NCLEX: Safe, Effective Care Environm
t:SCIN
oG
orTdB
in.C
atO
edMCare
33.
provides trained workers who come into the home for brief periods to relieve
parents of the responsibility of caring for the child.
ANS:
Respite care
Respite care provides trained workers who come into the home for brief periods to relieve parents of the
responsibility of caring for the child.
DIF: Cognitive Level: Knowledge REF: Page 494
TOP: Respite Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
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Chapter 22: Health Care Adaptations for the Child and Family
MULTIPLE CHOICE
1. What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant?
a. Brachial
b. Apical
c. Radial
d. Femoral
ANS: B
Apical pulses are advised for children under age 5 years.
DIF: Cognitive Level: Knowledge REF: Page 502
TOP: Physical Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on
the child. What should be the next action by the nurse?
a. Give the medication after confirming the childs name from the foot of the crib.
b. Ask the charge nurse to give the medicine.
c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.
d. Delay the medication until the admissions office can supply a new ID bracelet.
ANS: C
After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can
be safely given. All patients should be identified before treatment.
DIF: Cognitive Level: Application REF: Page 497
Bp.CleOmMentation
OBJ: 2 TOP: ID Bracelets KEY: Nursing ProcNeU
ssRSStIeNpG
:T
Im
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement
made by the adolescent led the nurse to determine she understood the instructions?
a. I should wash my perineum with soap and water, then begin to urinate.
b. I clean the perineum from front to back with an antiseptic wipe before I urinate.
c. Ill collect the first stream of urine in a sterile container.
d. I will discard the first void and collect a freshly voided specimen 30 minutes later.
ANS: B
To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.
DIF: Cognitive Level: Analysis REF: Page 508
TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4. Which strategy might the nurse use when administering oral medications to a young child who is reluctant?
a. Mix the medication with chocolate milk.
b. Tell the child that the medication is candy.
c. Give the medication quickly if the child is crying.
d. Offer the child fruit juice after the medication is swallowed.
ANS: D
The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been
swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk
because the child may develop distaste for it.
DIF: Cognitive Level: Application REF: Page 512
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A parent tells the nurse, Im not sure how to give this medicine to my infant. How would the nurse teach the
parent to best administer an oral suspension?
a. Pour the medication into a small cup and allowing the infant to drink it.
b. Place the medication in a nipple and having the infant suck the nipple.
c. Use an oral syringe and placing the medication in the side of the infants mouth.
d. Administer the medication with a dropper onto the back of the infants tongue.
ANS: C
An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is
placed midway back, at the side of the mouth.
DIF: Cognitive Level: Application REF: Page 513
TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when
administering the ear drops?
a. Up and back
b. Down and back
c. Up and out
d. Down and out
ANS: A
For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.
DIF: Cognitive Level: Application REF: Page 514
OBJ: 10 TOP: Administering Ear Drops
KEY: Nursing Process Step: Implementation NURSINGTB.COM
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. Why is a tympanic thermometer considered more accurate than other types of thermometers?
a. The thermometer probe is blunt and wide.
b. It takes a brief time to register.
c. The tympanic membrane shares circulation with the hypothalamus.
d. The tympanic membrane and the brain have the same temperature.
ANS: C
The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the
hypothalamus share the same circulation.
DIF: Cognitive Level: Knowledge REF: Page 506
TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
a. Discard the residual and increase the volume of feeding by the amount of residual.
b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
c. Refill the syringe with formula after it has completely emptied.
d. Position the child on the right side after a feeding.
ANS: D
To prevent regurgitation and aspiration, the child is placed in the Fowlers position or on the right side to
promote gastric emptying after a gastrostomy tube feeding.
DIF: Cognitive Level: Application REF: Page 526
OBJ: 13 TOP: Enteral Feedings
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Reduction of Risk
9. Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?
a. Mummy
b. Clove hitch
c. Jacket
d. Elbow
ANS: A
A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.
DIF: Cognitive Level: Comprehension REF: Page 499
OBJ: 12 TOP: Restraining the Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10. How often should a child who has a continuous intravenous infusion should be assessed?
a. Hourly
b. Every 2 hours
c. Every 3 hours
d. Every 4 hours
ANS: A
The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.
DIF: Cognitive Level: Knowledge REF: Page 516
TOP: Administering Parenteral Medications
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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11. The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied
as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide?
a. 1.25
b. 1.4
c. 1.6
d. 1.8
ANS: B
600,000_mL
5 mL 150,000 = 1.25 mL
This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an
infant.
DIF: Cognitive Level: Analysis REF: Page 520
OBJ: 9 TOP: Administering Injections
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. Which intervention will the nurse implement when suctioning a tracheostomy?
a. Suction for two to three breaths.
b. Clear the catheter with water after suctioning for reuse.
c. Apply suction for no more than 15 seconds.
d. Establish a regular schedule for suctioning.
ANS: C
Suctioning should be limited to 15 seconds.
DIF: Cognitive Level: Application REF: Page 527
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TOP: Respiration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. What emergency action should be implemented for airway obstruction in the infant?
a. Six to 10 midsternal thrusts
b. Five back blows followed by five chest thrusts
c. Five chest thrusts followed by five back blows
d. Abdominal thrusts until the object is expelled
ANS: B
Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the
infant.
DIF: Cognitive Level: Knowledge REF: Page 530
TOP: Management of Airway Obstruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. A 4-year-old asks tearfully if the IM injection will hurt. What is the nurses most effective response?
a. No. It is over before you know it.
b. Yes. It will sting a little.
c. No. Would you like to see the syringe?
d. Yes. Your mom and I are going to hold you to help you be still.
ANS: B
Truthful answers will give a child a realistic expectation and help establish trust in the nurse.
DIF: Cognitive Level: Application REF: Page 515
TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: CopinN
gU
anRdSIANdGaTpB
ta.tCioOnM
15. Where is the best site for giving an IM injection to a 15-month-old child?
a. Ventrogluteal muscle
b. Dorsogluteal muscle
c. Deltoid muscle
d. Vastus lateralis muscle
ANS: D
The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.
DIF: Cognitive Level: Application REF: Page 514
TOP: Administering Injections KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
16. What factor does the nurse explain affects the infants physiological response to medications?
a. Faster metabolism in the liver
b. Slower intestinal transit
c. Immature kidney function
d. Increased secretion of hydrochloric acid
ANS: C
Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of
age.
DIF: Cognitive Level: Comprehension REF: Page 511
TOP: Physiological Responses to Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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17. What intervention should the nurse implement after topical administration of hydrocortisone cream to the
buttocks and abdomen of an infant?
a. Diaper the infant snugly with a disposable diaper.
b. Cover the area with a transparent dressing.
c. Apply a cloth diaper.
d. Place the infant on a plastic pad, undiapered.
ANS: C
Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left
undiapered on a cloth pad.
DIF: Cognitive Level: Application REF: Page 511
TOP: Rapid Absorption of Drug KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. Which observation on entering the hospital room lets the nurse know that there is a need for the parents to
receive safety education to prevent unintentional injury?
a. The blanket is not tucked into the mattress.
b. Diapers and wipes are stacked at the foot of the crib.
c. The crib side is locked in the up position.
d. Pillows are stacked on the bedside table.
ANS: B
Disposable diapers and supplies must be kept out of the infants reach to prevent accidental suffocation.
DIF: Cognitive Level: Analysis REF: Page 498
OBJ: 2 TOP: Essential Safety Measures
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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19. A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will
assume for this procedure?
a. On your stomach with your head turned to the side.
b. On your side, keeping the legs bent and the head arched back.
c. On your back with your legs extended straight out.
d. On your side with the knees bent and the head close to the knees.
ANS: D
The child is positioned on his or her side with the knees flexed, and the head is brought down close to the
flexed knees.
DIF: Cognitive Level: Application REF: Page 510
OBJ: 8 TOP: Collecting SpecimensLumbar Puncture
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. The nurse is caring for a 4-year-old child. What will the nurse expect the childs daily urinary output to be?
a. 400 to 500 mL
b. 500 to 600 mL
c. 600 to 700 mL
d. 700 to 1000 mL
ANS: C
The average daily excretion of urine for a 4-year-old child is 600 to 700 mL.
DIF: Cognitive Level: Knowledge REF: Page 510
OBJ: 4 TOP: Collecting SpecimensUrine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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21. An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the
infants urine output?
a. 47 mL
b. 44.5 mL
c. 43.5 mL
d. 40.5 mL
ANS: B
Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper.
One gram is equivalent to one milliliter of output. 47 2.5 = 44.5 grams = 44.5 mL of urine.
DIF: Cognitive Level: Analysis REF: Page 524
OBJ: 4 TOP: Collecting SpecimensUrine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods
reduce the absorption of iron. What would be the best example provided by the nurse?
a. Red meat
b. Green, leafy vegetables
c. Acidic fruit juices
d. Egg yolks
ANS: D
Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons
taking an iron supplement.
DIF: Cognitive Level: Application REF: Page 525
OBJ: 2 TOP: Food/Drug Interactions
KEY: Nursing Process Step: Implementation NURSINGTB.COM
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23. The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital.
Which patient assessment requires immediate intervention?
a. Toddler with an axillary temperature of 99 F
b. School-age child with widening pulse pressure
c. Infant pulse rate of 100 beats per minute
d. Adolescent with a respiratory rate of 28 breaths per minute
ANS: B
A widening pulse pressure can indicate increased ICP; therefore it is the priority. An axillary temperature of 99
F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.
DIF: Cognitive Level: Application REF: Page 502
OBJ: 5 TOP: Vital signs KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will
the nurse maintain for this patient?
a. Left side-lying
b. Supine
c. Prone
d. Semi-Fowlers
ANS: B
The adolescent may avoid postlumbar puncture headache by lying flat for some time.
DIF: Cognitive Level: Application REF: Page 510
TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
25. Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a
procedure? (Select all that apply.)
a. Purpose of the procedure
b. Risks associated with the procedure
c. That no suit can be brought for damages
d. That the document must be signed and witnessed
e. That information was given
ANS: A, B, D, E
The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks
of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been
told; the document should be signed and witnessed.
DIF: Cognitive Level: Comprehension REF: Page 497
TOP: Informed Consent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
26. Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all
that apply.)
a. Insulin
b. Digoxin
c. Vasodilators
d. Calcium salts
e. Anticoagulants
ANS: A, B, D, E
NURSINGTB.COM
Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all
must be checked by a licensed nurse prior to administration.
DIF: Cognitive Level: Comprehension REF: Page 518
TOP: Drug Administration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
27. A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse
implement? (Select all that apply.)
a. Assess rectal temperature every 4 hours.
b. Administer Acetaminophen as ordered.
c. Assess skin turgor.
d. Restrict fluids.
e. Assess level of consciousness.
ANS: B, C, E
When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the
child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not
respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants
and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the
child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for
pediatric patients.
DIF: Cognitive Level: Application REF: Page 503
OBJ: 6 TOP: Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28. What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all
that apply.)
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a. Age
b. Race
c. Vital signs
d. Distance to travel
e. Level of consciousness
ANS: A, D, E
The means by which the child is transported within the unit and to other parts of the hospital depends on age,
level of consciousness, and how far the child must travel.
DIF: Cognitive Level: Comprehension REF: Page 499
TOP: Modes of Transportation KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
29. The nurse is searching through several blood pressure cuffs to find a cuff that is the appropriate size for her
small patient. The nurse selects a cuff that covers
of the patients upper arm.
ANS:
two thirds
No matter the age of the patient, for the blood pressure cuff to provide an accurate reading it should cover two
thirds of the upper arm. A smaller cuff will give an inaccurately high reading and a larger cuff will give an
inaccurately low reading.
DIF: Cognitive Level: Application REF: Page 503
OBJ: 4 TOP: Selection of Blood Pressure Cuff
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: BasicNCUaR
reSIaN
ndGT
CBo.m
rt
CfOoM
30. The nurse is aware that for the 3-month-old who has a surgery time of 2:30 PM, the start order for NPO
should be no earlier than
.
ANS:
8:30 AM
Periods of NPO should not exceed 4 to 6 hours for pediatric clients because they can become dehydrated very
quickly.
DIF: Cognitive Level: Application REF: Page 520
TOP: NPO Orders in Infants KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
31. The order reads, Give ampicillin oral suspension 400 mg PO every day. The vial reads, Ampicillin 125
mg/5 mL. The nurse will give a dose of
mL.
ANS: 16
DIF: Cognitive Level: Analysis REF: Page 520
TOP: Pediatric Dose Calculation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
32. The physician has ordered phenytoin syrup 20 mg PO bid for a child who weighs 15 pounds. The PDR
states that 10 mg/kg/day is the maximum daily dose. The safe daily dose of this medication is
mg.
ANS:
34
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15 pounds = 6.8 kilograms; 6.8 10 mg = 68 mg maximum daily dose, making the bid doses 34 mg each
DIF: Cognitive Level: Analysis REF: Page 513
TOP: Dose Calculation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
33. After instilling nose drops, the nurse will keep the infant in the head down position for at least
seconds.
ANS:
30
The retained position for 30 seconds to 1 minute allows the nose drops to enter deeply into the nostril.
DIF: Cognitive Level: Comprehension REF: Page 513
OBJ: 10 TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
34. The nurse is aware that because of the function of the mist tent that a child is at risk for
.
ANS:
hypothermia
Children in mist tents are at risk for hypothermia because of the high humidity and the cooled oxygen. These
children should be dressed warmly and changed frequently. The bed linens should be changed frequently as
they absorb moisture from the tent as well.
DIF: Cognitive Level: Comprehension REF: Page 529
OBJ: 14 TOP: Mist Tent KEY: Nursing Process Step: Planning
CfOoM
MSC: NCLEX: Physiological Integrity: BasicNCUaR
reSIaN
ndGT
CBo.m
rt
35. An
implies that the parent or legal guardian is capable of understanding
information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to tha
procedure.
ANS:
informed consent
An informed consent implies that the parent or legal guardian is capable of understanding information given to
him or her, including the purpose and risks of the procedure, and voluntarily agrees to that procedure.
DIF: Cognitive Level: Knowledge REF: Page 497
TOP: Informed Consent KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
36. When obtaining a urine specimen on an infant, the adhesive of the urine collector is placed between the
and the
.
ANS:
anus, perineum
Begin by applying the urine collector to the tiny area of skin between the anus and the perineum. The narrow
bridge on the adhesive patch keeps feces from contaminating the specimen and helps to position the collector
correctly.
DIF: Cognitive Level: Knowledge REF: Page 509
OBJ: 7 TOP: Urine Specimen Collection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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Chapter 23: The Child with a Sensory or Neurological Condition
MULTIPLE CHOICE
1. A parent comments that her infant has had several ear infections in the past few months. Why are infants
more susceptible to otitis media?
a. Infants are in a supine or prone position most of the time.
b. Sucking on a nipple creates middle ear pressure.
c. They have increased susceptibility to upper respiratory tract infections.
d. The eustachian tube is short, straight, and wide.
ANS: D
An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle
ear.
DIF: Cognitive Level: Knowledge REF: Page 538
TOP: Otitis Media KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What statement by a patients mother leads the nurse to determine she understands instructions about
administering an oral antibiotic for otitis media?
a. I will continue using the medication until symptoms are relieved.
b. I will share the medicine with siblings if their symptoms are the same.
c. I will give the medication with a glass of milk.
d. I will administer prescribed doses until all the medication is used.
ANS: D
Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if
symptoms are alleviated.
NURSINGTB.COM
DIF: Cognitive Level: Application REF: Page 540
OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. Which situation would cause the nurse to suspect a hearing impairment?
a. 3-month-old infant with a positive Moro reflex
b. 15-month-old toddler who is babbling
c. 18-month-old toddler who is speaking one-syllable words
d. 24-month-old toddler who communicates by pointing
ANS: D
The child who is not making verbal attempts by 18 months should undergo a complete physical examination.
DIF: Cognitive Level: Analysis REF: Page 540
OBJ: 3 TOP: Hearing Impairment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
a. Use gestures and signs as much as possible.
b. Let the childs parents communicate for her.
c. Face the child and speak clearly in short sentences.
d. Recognize that the childs ability to communicate will be on a 6-year-old childs level.
ANS: C
The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop
a healthy personality.
DIF: Cognitive Level: Application REF: Page 541
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OBJ: 3 TOP: Hearing Impairment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
5. What would the nurse include when planning postoperative teaching for a child who has had a
tympanostomy with insertion of tubes?
a. Keeping the infant flat after feeding
b. Giving over-the-counter decongestants
c. Avoiding getting water in the ears
d. Cleaning the ear canal with cotton-tipped applicators
ANS: C
After a tympanostomy, care should be taken to avoid getting water in the ears.
DIF: Cognitive Level: Comprehension REF: Page 540
TOP: Postoperative Care of Tympanostomy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. What assessment made by the school nurse would lead to the suspicion of strabismus?
a. Reddened sclera in one eye
b. Child covers one eye to read the chalkboard
c. Child complains of a headache
d. Copious tears while watching TV
ANS: B
Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts
to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point
suspicion to any disorder.
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DIF: Cognitive Level: Analysis REF: Page 543
OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. What might the nurse explain as a common treatment for amblyopia?
a. Patching the good eye to force the brain to use the affected eye
b. Patching the affected eye to allow the refractory muscles to rest
c. Using glasses that will slightly blur the image for the good eye
d. Using corticosteroids to treat inflammation of the optic nerve
ANS: A
Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good
eye and using glasses to correct refractive errors.
DIF: Cognitive Level: Knowledge REF: Page 543
TOP: Amblyopia KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. What assessment does the school nurse recognize as the cardinal sign of a hyphema?
a. Opacity of the lens
b. A yellow-white reflex on the pupil
c. A dark-red spot in front of the iris
d. Inflamed mucous membranes of the eyelids
ANS: C
A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.
DIF: Cognitive Level: Knowledge REF: Page 545
TOP: Hyphema KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the
nurse include in this teaching?
a. Use aspirin instead of acetaminophen for children with viral illness.
b. Advise parents to have their children immunized against Reyes syndrome.
c. Avoid giving salicylate-containing medications to a child who has viral symptoms.
d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.
ANS: C
Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children
with viral symptoms.
DIF: Cognitive Level: Application REF: Page 546
TOP: Reyes Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of
Reyes syndrome?
a. Respirations drop from 18 to 14 breaths/min
b. Falling asleep after feeding
c. Sudden vomiting without effort
d. Development of a macular rash
ANS: C
A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy,
and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal.
DIF: Cognitive Level: Application REF: Page 546
TOP: Reyes Syndrome KEY: Nursing ProcessNSUtR
epS:IN
DG
atTaBC.C
oO
lleM
ction
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. What does the nurse explains to parents of a child with febrile seizures?
a. They occur when the body temperature exceeds 38.3 C (101 F).
b. They can be prevented by anticonvulsant medication.
c. They usually lead to the development of epilepsy.
d. They occur when the temperature rises quickly.
ANS: D
Febrile seizures occur in response to a rapid rise in temperature, often above 38.8 C (102 F).
DIF: Cognitive Level: Comprehension REF: Page 552
TOP: Febrile Seizures KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. A parent reports that her child has begun to do poorly at school and experiences episodes where he appears
to be staring into space. Of which type of seizure is this behavior a characteristic?
a. Absence
b. Akinetic
c. Myoclonic
d. Complex partial
ANS: A
Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly,
and may last only a few seconds.
DIF: Cognitive Level: Comprehension REF: Page 553
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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13. An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the
nurse should call 911?
a. The seizure lasts more than 5 minutes.
b. The child is sleepy and lethargic after the seizure.
c. The child fell at the onset of the seizure.
d. The child is confused and has slurred speech after the seizure.
ANS: A
If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of
possible status epilepticus, a medical emergency.
DIF: Cognitive Level: Application REF: Page 553
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
a. Guide the child to the floor if the child is standing, and then go for help.
b. Move objects out of the childs immediate area.
c. Stick a padded tongue blade between the childs teeth.
d. Manually restrain the child.
ANS: B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.
DIF: Cognitive Level: Application REF: Page 553
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would
the nurse expect to assess after a generalized tN
onUiR
c-ScIlN
onGiT
c Bse.CizOuM
re?
a. Restlessness
b. Sleepiness
c. Nausea
d. Anxiety
ANS: B
Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time
(postictal lethargy) and then return to full consciousness.
DIF: Cognitive Level: Comprehension REF: Page 553
OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. What would the nurse include when creating a teaching plan that includes the long-term administration of
phenytoin (Dilantin)?
a. The medication should be given on an empty stomach.
b. Insomnia can be a significant side effect.
c. Gums should be massaged regularly to prevent hyperplasia.
d. Blood pressure should be closely monitored.
ANS: C
Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes
drowsiness and should be given with meals at the same time each day.
DIF: Cognitive Level: Comprehension REF: Page 556
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits
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jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral
palsy?
a. Athetoid
b. Ataxic
c. Spastic
d. Mixed
ANS: C
Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles
jerky and uncoordinated.
DIF: Cognitive Level: Comprehension REF: Page 557
OBJ: 12 TOP: Cerebral Palsy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. Which assessment finding in a child with meningitis should be reported immediately?
a. Irregular respirations
b. Tachycardia
c. Slight drop in blood pressure
d. Elevated temperature
ANS: A
Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported
immediately because they could indicate increased intracranial pressure.
DIF: Cognitive Level: Application REF: Page 549
TOP: Meningitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
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19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands
pronated. How does the nurse identify this posture?
a. Correct anatomical position
b. Decorticate
c. Decerebrate
d. Opisthotonos
ANS: C
In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture
indicates brainstem function only.
DIF: Cognitive Level: Application REF: Page 563
OBJ: 15 TOP: Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. What will the nurse teach parents when giving instructions for acute conjunctivitis?
a. Apply cool compresses to the affected eye several times a day.
b. Instill topical steroid eye drops for 1 week.
c. Clear drainage from the inner to the outer aspect of the eye.
d. Keep the eye patched until the inflammation resolves.
ANS: C
Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to
outer direction).
DIF: Cognitive Level: Application REF: Page 545
TOP: Conjunctivitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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21. A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing
assessment suggests the child has a concussion?
a. Sleepy but easily arousable
b. Complaining of a stiff neck
c. Cannot remember what happened to him
d. Pupils react sluggishly to light
ANS: C
A concussion is a temporary disturbance of the brain that is immediately followed by a period of
unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before,
during, or after the injury.
DIF: Cognitive Level: Analysis REF: Page 561
OBJ: 16 | 17 TOP: Head Injury KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks
she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?
a. Meningitis
b. Reyes syndrome
c. Brain tumor
d. Encephalitis
ANS: C
The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased
intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.
DIF: Cognitive Level: Analysis REF: Page 551
TOP: Brain Tumor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: PhysiN
olUoR
giScIaNl G
ATdB
ap.CtaOtiM
on
23. The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type
B. What does this immunization protect against?
a. Encephalitis
b. Influenza
c. Bacterial meningitis
d. Otitis media
ANS: C
H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial
meningitis.
DIF: Cognitive Level: Knowledge REF: Page 549
OBJ: N/A TOP: Prevention of Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24. The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report
the probability of increasing intracranial pressure (ICP)?
a. Temperature increase from 37.2 C (99 F) to 37.7 C (100 F)
b. Increase in blood pressure with an attendant decrease in pulse
c. Increase in respirations
d. Equilateral pupils
ANS: B
Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are
indicators of ICP.
DIF: Cognitive Level: Comprehension REF: Page 565
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TOP: ICP KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25. A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?
a. Patching the unaffected eye
b. Corrective lenses
c. Laser treatment
d. Surgery
ANS: B
In nonparalytic strabismus the refractory error is usually corrected with eyeglasses.
DIF: Cognitive Level: Comprehension REF: Page 544
OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they
implement in dealing with various challenges. Which of the following a statements by the parents alerts the
nurse that they need further instruction?
a. We dress our son every morning for school.
b. Our son participates in the Special Olympics every year.
c. Our son attends play therapy at a center close to home.
d. We attend a support group once a week.
ANS: A
The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not take over
projects because of their own need to assist or speed up the process.
DIF: Cognitive Level: Application REF: Page 561
TOP: Cognitive Impairment KEY: Nursing PrN
oU
ceRsS
s ISNteGpT:BIm
.CpOleMmentation
MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment
27. What would the nurse include in teaching when preparing to teach parents about air travel instructions to
prevent barotrauma in infants?
a. Using ear plugs during takeoff
b. Omitting the meal just before takeoff
c. Letting the infant nurse during descent
d. Applying ear drops before takeoff
ANS: C
Encouraging an infant to swallow reduces the pressure in the ears during descent.
DIF: Cognitive Level: Comprehension REF: Page 542
TOP: Barotrauma KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
28. Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6month-old child? (Select all that apply.)
a. Hypersensitivity to noise
b. Irritability
c. Reddened ear canal
d. Rolls head from side to side
e. Temperature of 39.4 C (103 F)
ANS: B, D, E
Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and
pulling at or rubbing their ears.
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DIF: Cognitive Level: Comprehension REF: Page 539
OBJ: 2 TOP: Indications of Ear Infection
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
29. Which aspect(s) of a childs development does the nurse caution parents that hearing impairment can affect?
(Select all that apply.)
a. Speech clarity
b. Language development
c. Immunity to disease
d. Personality development
e. Academic achievement
ANS: A, B, D, E
All the options, except immunity to disease, are areas in which a hearing impairment could interfere with
normal development.
DIF: Cognitive Level: Comprehension REF: Page 540
TOP: Hearing Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that
apply.)
a. Isolation precautions
b. Provision of brightly lit room
c. Observation for increasing intracranial pressure
d. Preparation for spinal tap
e. Seizure precautions
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ANS: A, C, D, E
All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive
care of a child with meningitis.
DIF: Cognitive Level: Application REF: Page 550
TOP: Nursing Care of Child with Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31. What will the nurse include then documenting a grand mal seizure? (Select all that apply.)
a. Presence of incontinence
b. Current dose of antispasmodic medication
c. Activity level prior to and following seizure
d. Level of consciousness following seizure
e. Length of seizure
ANS: A, C, D, E
Documentation on a seizure should include LOC following episode, activity prior to and following seizure,
change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not
necessary.
DIF: Cognitive Level: Application REF: Page 552
TOP: Documentation of Seizure KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
32. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will
the nurse include? (Select all that apply.)
a. Encourage books with large type.
b. Words in books should be closely spaced.
c. Provide adequate lighting without glare.
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d. Be sure desks and chairs are adequate height.
e. Instruct child to squint when reading.
ANS: A, C, D
Children who are beginning to read need books with large type in which the letters are spaced far apart. The
lighting must be adequate and without glare. Chairs and desks must be of the proper height.
DIF: Cognitive Level: Comprehension REF: Page 545
TOP: Decorticate Posturing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
33. The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow
Coma Scale. What score will the nurse give if the child is babbling?
a. 1
b. 2
c. 3
d. 4
ANS: D
If babbling, the 10-month-old infant receives a score of 4 for responses.
DIF: Cognitive Level: Application REF: Page 566
OBJ: 18 TOP: Neurological Monitoring/Infants
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
34. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented?
(Select all that apply.)
a. Parental education regarding prevention
b. Respiratory support
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c. Cardiovascular support
d. Controlled rewarming
e. Adequate cerebral oxygenation
ANS: B, C, D, E
Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral
oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and
referral to social services, religious, or community agencies for follow-up.
DIF: Cognitive Level: Comprehension REF: Page 566
OBJ: 19 TOP: Near-drowning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
35. The sign that suggests possible damage to the cortex of the brain is
posturing.
ANS:
decorticate
Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to
the brain cortex.
DIF: Cognitive Level: Comprehension REF: Page 563
TOP: Decorticate Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
36. The nurse records the finding of
when the child with meningitis cries
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out in pain when his head is flexed toward his chest.
ANS:
nuchal rigidity
Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal rigidity.
DIF: Cognitive Level: Comprehension REF: Page 549
TOP: Nuchal Rigidity KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
37. The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the
nerve.
ANS:
hypoglossal
The hypoglossal (XII) nerve allows the infant to be able to suck and swallow. It is also responsible for tongue
movement.
DIF: Cognitive Level: Knowledge REF: Page 548
OBJ: 7 TOP: Cranial Nerves
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
38.
occurs when there is a change in the atmospheric pressure between the internal body
systems and the surrounding environment.
ANS:
Barotrauma
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Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and
the surrounding environment.
DIF: Cognitive Level: Knowledge REF: Page 542
TOP: Barotrauma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
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Chapter 24: The Child with a Musculoskeletal Condition
MULTIPLE CHOICE
1. What would the nurse include in planning teaching to parents of a child with Legg-Calv-Perthes disease
about the long-term effects of this disease?
a. There are no long-term effects.
b. The disease is self-limited and requires no long-term treatment.
c. Degenerative arthritis may develop later in life.
d. There is risk of osteogenic sarcoma in adulthood.
ANS: C
Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip
later in life.
DIF: Cognitive Level: Comprehension REF: Page 582
TOP: Legg-Calv-Perthes Disease KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. What intervention will the nurse caring for a child in Bucks skin traction implement?
a. Position in high Fowlers position.
b. Assist the child to be pulled up in bed.
c. Keep childs heel on the bed surface.
d. Maintain childs feet against the foot of the bed.
ANS: B
Bucks traction is a type of skin traction that relies on the childs weight as counterbalance. The child must be
kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed
surface or the foot of the bed.
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DIF: Cognitive Level: Application REF: Page 574
TOP: Bucks Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What will the nurse include when caring for a child in Bucks extension?
a. Positioning the child with hips flexed 90 degrees at all times
b. Keeping the weights in contact with the floor
c. Checking for skin irritation from traction equipment
d. Releasing the weights on a schedule
ANS: C
The skin exposed to frequent friction may break down.
DIF: Cognitive Level: Application REF: Page 577
OBJ: 6 TOP: Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. The nurse is reviewing the characteristics of Ewings sarcoma. Which statement if made by the nurse
indicates correct understanding of this disease?
a. Amputation is the accepted treatment.
b. The disease is sensitive to radiation and chemotherapy.
c. Metastasis is rare.
d. The disease is more prevalent among toddlers and preschoolers.
ANS: B
Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is
not recommended. This cancer occurs in school-age children and does metastasize.
DIF: Cognitive Level: Comprehension REF: Page 583
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TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
5. What characteristic manifestation does the nurse caring for a child with Duchennes muscular dystrophy
document?
a. Ambulates by holding onto furniture
b. Exhibits atrophy of the calf muscles
c. Falls frequently and is clumsy
d. Has delayed fine-motor development
ANS: C
Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy.
DIF: Cognitive Level: Knowledge REF: Page 581
TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are
swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type of
juvenile rheumatoid arthritis do these findings suggest?
a. Psoriatic
b. Enthesitis
c. Systemic
d. Acute febrile
ANS: C
The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte
sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.
DIF: Cognitive Level: Application REF: PageN5U8R
3 SINGTB.COM
TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does
the nurse recognize as indicative of a need for additional teaching?
a. Apply warm compresses to the ankle for the first 24 hours.
b. Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off.
c. Wrap the ankle in an Ace bandage for support.
d. Keep the leg elevated when sitting.
ANS: A
Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice,
compression, and elevation.
DIF: Cognitive Level: Application REF: Page 573
OBJ: 4 TOP: Soft Tissue Injury
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. How does Russell traction provide adequate skin traction?
a. Subluxates the tibia
b. Does not interfere with range of motion
c. Prevents the knee from flexing
d. Supplies continuous pull in two directions
ANS: D
Russell traction is skin traction, similar to Bucks, with a sling positioned under the knee, which prevents
subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position
without disrupting the continuous pull in two directions.
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DIF: Cognitive Level: Comprehension REF: Page 574
TOP: Russell Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. The nurse is checking for capillary refill on a child in Bryants traction. How long does it take for the toe to
regain color if adequate perfusion is assessed?
a. 3 seconds
b. 4 seconds
c. 5 seconds
d. 6 seconds
ANS: A
Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.
DIF: Cognitive Level: Comprehension REF: Page 577
OBJ: 8 TOP: Fracture KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond
causes the pain experienced with osteomyelitis?
a. Pressure of inelastic bone
b. Purulent drainage in the bone marrow
c. The cast applied on the extremity
d. Circulatory congestion of the skin
ANS: B
Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow
and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS5I8N0GTB.COM
OBJ: N/A TOP: Osteomyelitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to
know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will
probably last?
a. 2 weeks
b. 6 weeks
c. 2 months
d. 3 months
ANS: B
Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.
DIF: Cognitive Level: Application REF: Page 580
OBJ: 1 TOP: Osteomyelitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
12. What finding would the nurse assessing the neurovascular status of a child in Russell traction report
immediately?
a. Skin thats warm to the touch
b. Capillary refill less than 3 seconds
c. Ability to wiggle toes
d. Bluish coloration of skin
ANS: D
Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.
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DIF: Cognitive Level: Application REF: Page 577
OBJ: 7 | 8 TOP: Neurovascular Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the cause of this
spinal curvature defect?
a. Juvenile rheumatoid arthritis
b. Poor posture
c. Heredity
d. Myelomeningocele
ANS: B
Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.
DIF: Cognitive Level: Comprehension REF: Page 584
OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis?
a. Ask the child to bend forward at the waist and observe the childs back for asymmetry.
b. Observe the gait while the child is walking forward heel to toe.
c. Have the child flex the knees and look for uneven knee height.
d. Look at the childs shoulders and hips while fully clothed.
ANS: A
The nurse looks at the back as the child bends forward for general body alignment and asymmetry.
DIF: Cognitive Level: Application REF: Page 584
OBJ: 13 TOP: Scoliosis KEY: Nursing ProcesNsUSR
teSpI:NDGaTtaB.CCoOllM
ection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. What nursing action will significantly decrease the risk of serious complications for a child in Bryants
traction?
a. Neurovascular checks are done frequently.
b. Bandages are wrapped tightly.
c. The child is restrained from rolling over.
d. The childs buttocks are resting on the bed.
ANS: A
The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is
obstructed.
DIF: Cognitive Level: Application REF: Page 576
TOP: Traction: Volkmanns Ischemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid
arthritis?
a. Wearing splints at night to prevent extension contractures
b. Applying moist heat packs upon awakening
c. Taking a warm tub bath the evening before
d. Sleeping with two pillows under the head
ANS: B
Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness.
DIF: Cognitive Level: Application REF: Page 583
TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?
a. Wear the brace directly against the skin.
b. Wear the brace over regular clothing.
c. Wear the brace over a T-shirt 23 hours a day.
d. Remove the brace before sleeping.
ANS: C
A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.
DIF: Cognitive Level: Application REF: Page 584
TOP: Scoliosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. Which observation may cause the nurse to consider the possibility of child abuse when a mother says that
her young child fell down the basement stairs?
a. Red, green, and yellow bruises on his body
b. Bruises are dispersed on his head, arms, and legs
c. A broken arm last year, and the child being described as accident-prone
d. The mother is very anxious for her son to get medical attention
ANS: A
As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all
occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of
what happened.
DIF: Cognitive Level: Analysis REF: Page 589
OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and MainteN
naUnRcSe:INPG
reTvBen.CtiO
oM
n and Early Detection of Disease
19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain
when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child?
a. Pain resulting from tissue trauma
b. High risk for impaired skin integrity resulting from immobility
c. Altered growth and development related to separation from family
d. Altered urinary elimination related to immobility and traction
ANS: A
Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm
and tissue trauma is the highest priority.
DIF: Cognitive Level: Analysis REF: Page 579
OBJ: 7 TOP: The Child with a Fracture in Traction
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child?
a. Has inward-turned knees while standing
b. Walks on the toes
c. Appears to have flat feet
d. Swings his arms when walking
ANS: B
Toe walking after 3 years of age may indicate a muscle problem.
DIF: Cognitive Level: Analysis REF: Page 571
TOP: Assessment of the Musculoskeletal System
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. Why does a childs fracture heal more rapidly than the adults?
a. A childs bones are less porous than adult bone.
b. A childs bones are covered by a thicker periosteum.
c. A childs bones are not affected by bone overgrowth.
d. A childs bones have faster callus formation.
ANS: D
Callus forms more rapidly in the child than the adult.
DIF: Cognitive Level: Knowledge REF: Page 574
TOP: Differences Between the Child and Adult
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. On entering the room of a child in Bucks traction, the nurse makes all of the following observations. Which
observation requires a nursing intervention?
a. Childs heels are placed firmly against the foot of the bed.
b. Head of bed is elevated 20 degrees.
c. Weights are hanging freely.
d. Ropes are on pulleys.
ANS: A
Bucks traction is dependent on the child as a counterweight. The heels should be elevated above the level of
the foot of the bed.
DIF: Cognitive Level: Application REF: Page 574
TOP: Bucks Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: BasicNCUaR
reSIaN
ndGT
CBo.m
rt
CfOoM
23. Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be?
a. 2 days
b. 4 days
c. 6 days
d. 8 days
ANS: C
Bruises heal in various stages that are indicated according to color; after 5 to 7 days bruise are green.
DIF: Cognitive Level: Comprehension REF: Page 589
OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24. A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of
fracture would be the most likely to alert the nurse to the possibility of physical abuse?
a. Stress fracture
b. Compound fracture
c. Spiral fracture
d. Greenstick fracture
ANS: C
A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not
correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of
manual twisting of the extremity.
DIF: Cognitive Level: Comprehension REF: Page 574
TOP: Fractures/Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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25. Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast?
a. Risk for altered peripheral tissue perfusion
b. Risk for altered urine elimination
c. Knowledge deficit
d. Risk for infection
ANS: A
Casting can lead to compromised tissue perfusion caused by increased pressure from edema or swelling
pressing on the tissues. Neurovascular checks are an assessment priority.
DIF: Cognitive Level: Application REF: Page 576
OBJ: 9 TOP: Casting KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
26. A child is sent to the school nurse for assessment because she comes to school every day disheveled,
unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these
finding indicate?
a. Sexual abuse
b. Physical abuse
c. Physical neglect
d. Emotional abuse
ANS: C
Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing,
shelter, and basic cleanliness.
DIF: Cognitive Level: Comprehension REF: Page 587
TOP: Child Abuse Triggers KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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27. Which assessment performed by a nursing student performing a neurovascular check alerts the instructor
that further education is necessary?
a. Pulses
b. Capillary refill
c. Movement
d. Pupils
ANS: D
Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement.
Pupils are assessed with a neurological check.
DIF: Cognitive Level: Comprehension REF: Page 577
TOP: Neurovascular Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
28. What factor(s) may trigger abuse in a parent? (Select all that apply.)
a. Being abused as a child
b. High self-esteem
c. Substance abuse
d. Overwhelming responsibility
e. Knowledge deficit relative to child care
ANS: A, C, D, E
All options except high self-esteem are possible triggers for a parent to become abusive.
DIF: Cognitive Level: Comprehension REF: Page 587
OBJ: 15 TOP: Child Abuse Triggers
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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
29. The nurse demonstrates which similarities among all traction devices? (Select all that apply.)
a. Pull the limb into extension
b. Decrease muscle spasm
c. Reduce pain
d. Align two bone fragments
e. Immobilize the limb
ANS: A, B, D, E
Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and
decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.
DIF: Cognitive Level: Comprehension REF: Page 574
OBJ: 7 TOP: Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. The nurse performing a neurovascular check on a limb in traction would report and document which
finding(s) as indicative of altered circulation? (Select all that apply.)
a. Pulse is equal to uncasted limb.
b. Patient is aware of touch and warm and cold application.
c. Limb is cool to the touch.
d. Capillary refill is 5 seconds.
e. Distal limb can flex and extend.
ANS: C, D
The limb should be warm, and capillary refill should be less than 3 seconds.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS5I7N7GTB.COM
OBJ: 8 TOP: Neurovascular Assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
31. How does the pediatric skeletal system differ from that of the adult? (Select all that apply.)
a. Lower mineral content
b. More ossification
c. Open epiphyses
d. Less porosity
e. Greater strength
ANS: A, C, E
The childs skeletal system has less mineral content, greater porosity, open epiphyses, greater bone strength,
and a thicker periosteum.
DIF: Cognitive Level: Comprehension REF: Page 570
OBJ: 2 TOP: Skeletal Differences KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
32. The nurse explains that Bryants traction is reserved for children who weigh less than
pounds.
ANS:
30
Bryants traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh
less than 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues.
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DIF: Cognitive Level: Knowledge REF: Page 574
TOP: Bryants Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
33. The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weightbearing activities during treatment with radiation to reduce the risk of a(n)
fracture.
ANS:
pathological
The bone has lost its integrity because of the cancer and radiation. Excessive or vigorous weight bearing can
cause a pathological fracture of the compromised bone.
DIF: Cognitive Level: Application REF: Page 583
TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
34. The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to
a standing position. The nurse recognizes this characteristic behavior as
maneuver.
ANS:
Gowers
Gowers maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body
erect.
DIF: Cognitive Level: Knowledge REF: Page 581
TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
NURSINGTB.COM
35. The nurse recognizes the signs of
syndrome in a child in 90-90 traction when the
toes are pale and edematous and have a very slow capillary refill.
ANS:
compartment
When a limb is in traction or has been cast, the caregiver must check for adequate perfusion of the limb.
Compartment syndrome occurs when the attendant edema from the injury or the traction compromises the
circulation. This is an emergency and must be corrected before permanent damage can occur.
DIF: Cognitive Level: Comprehension REF: Page 577
TOP: Compartment Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36. A nurse assessing welts on the body of a 2-year-old Vietnamese child should consider the skin lesions
might be the result of the cultural practice of
.
ANS:
coining
Some Vietnamese place heated coins on the body to cure disease. This practice leaves welts that are sometimes
mistaken for child abuse.
DIF: Cognitive Level: Comprehension REF: Page 589
TOP: Cultural Practices: Coining KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
37.
is a condition in which neck motion is limited and the cervical spine is rotated
because of shortening of the sternocleidomastoid muscle.
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ANS:
Torticollis
Torticollis (tortus, twisted, and collium, neck) is a condition in which neck motion is limited and the cervical
spine is rotated because of shortening of the sternocleidomastoid muscle. It can be either congenital or
acquired and can also be either acute or chronic.
DIF: Cognitive Level: Knowledge REF: Page 583
TOP: Torticollis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 25: The Child with a Respiratory Disorder
MULTIPLE CHOICE
1. What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus
that the treatment is most likely to be?
a. Acetaminophen and plenty of fluids
b. Oral penicillin for 10 days
c. Penicillin until his sore throat is gone
d. Streptococcus immunization
ANS: B
When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10
days even if symptoms are alleviated before the medication is finished.
DIF: Cognitive Level: Comprehension REF: Page 596
TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
2. Which initial intervention will the nurse suggest to the parents of a child experiencing laryngeal spasm?
a. Take the child outside in the cool air.
b. Bring the child directly to the emergency department.
c. Take the child to the bathroom and turn on a hot shower.
d. Have the child drink plenty of fluids.
ANS: C
The child experiencing laryngeal spasm should be placed in a high-humidity environment, such as the
bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.
DIF: Cognitive Level: Application REF: PageN5U9R
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TOP: Croup Syndromes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A).
What might this indicate?
a. Bleeding from the surgical site
b. Pain at the incision area
c. Sore throat from postnasal drip
d. Potential vomiting
ANS: A
Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs
throat could cause frequent swallowing.
DIF: Cognitive Level: Comprehension REF: Page 604
TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. What is the best choice for fluid replacement that the nurse can offer a child who has just had a
tonsillectomy?
a. A popsicle
b. Chocolate milk
c. Orange juice
d. Cola drink
ANS: A
Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural
juices. A popsicle is usually well-tolerated.
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DIF: Cognitive Level: Application REF: Page 604
TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the
nurse immediately report?
a. Respiration rate decrease from 40 to 32 breaths/min
b. Heart rate decrease from 110 to 100 beats/min
c. Quiet chest from previous assessment of wheezing
d. Oxygen saturation of 90%
ANS: C
A quiet chest after assessment of wheezing indicates occlusion of air pathways and impending respiratory
arrest. All other options are within normal range for infants undergoing oxygen administration.
DIF: Cognitive Level: Analysis REF: Page 600
TOP: Respiratory Syncytial Virus (RSV)
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma
attack, expect to find?
a. Fine crackles
b. Coarse rhonchi
c. Expiratory wheezing
d. Decreased breath sounds at lung bases
ANS: C
The child experiencing an acute asthma attack wheezes as air moves in and out of the narrowed airways. The
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expiratory wheeze is most pronounced.
DIF: Cognitive Level: Knowledge REF: Page 605
OBJ: 12 TOP: Asthma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What is the best intervention for the nurse caring for a child experiencing an acute asthma attack?
a. Offer plenty of fluids, particularly carbonated beverages.
b. Place the child in a humidified cool mist tent with oxygen.
c. Administer sedatives as ordered to decrease anxiety.
d. Position the child with arms resting on the overbed table.
ANS: D
This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would
mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.
DIF: Cognitive Level: Comprehension REF: Page 609
TOP: Asthma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale
Cromolyn?
a. Before exercise to prevent attacks
b. At the initial onset of the attack
c. During the attack to relieve symptoms
d. As often as 4 times a day
ANS: A
Anti-inflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the
attack in progress. They are meant to be used as prophylactic therapies.
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DIF: Cognitive Level: Application REF: Page 609
TOP: Asthma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease,
because no one in either of their families has CF. What is the nurses best response based on the understanding
of CF?
a. Only one parent carries the CF gene.
b. Both parents are carriers of the CF gene.
c. The inheritance pattern is multifactorial.
d. The result is probably a genetic mutation.
ANS: B
Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the
disease.
DIF: Cognitive Level: Comprehension REF: Page 611
TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. Which statement indicates that the childs parents understand how to perform respiratory therapy?
a. We do her postural drainage before the aerosol therapy.
b. We give her respiratory treatments when she is coughing a lot.
c. We give the aerosol followed by postural drainage before meals.
d. She needs respiratory therapy every day when she has an infection.
ANS: C
Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals
or at least 1 hour after eating to prevent vomiting.
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DIF: Cognitive Level: Analysis REF: Page 615
TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11. What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption
of nutrients?
a. Pancreatic enzymes
b. Water-soluble minerals
c. Fat-soluble vitamins
d. Salt supplements
ANS: A
An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic
enzymes that the childs body cannot produce.
DIF: Cognitive Level: Knowledge REF: Page 615
TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. How would the nurse advise a mother to clear the nostrils when her infant has a cold?
a. Clear the nasal passages after the infant has a feeding.
b. Use over-the-counter nose drops to clear passages.
c. Remove nasal secretions with a bulb syringe.
d. Instill saline nose drops after clearing away secretions.
ANS: C
The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the
secretions with a bulb syringe.
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DIF: Cognitive Level: Application REF: Page 596
TOP: Nasopharyngitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through
dyspnea. Which fluids are most appropriate?
a. Room temperature water
b. Carbonated beverages
c. Iced fruit juice
d. Cold milk
ANS: A
Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk stimulates mucus
production.
DIF: Cognitive Level: Application REF: Page 609
TOP: Asthma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
14. The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is
sweating profusely. What does the nurse recognize as the cause of these symptoms?
a. Severe asthma attack
b. Allergic response to theophylline
c. Onset of bronchitis
d. Drug toxicity
ANS: D
The symptoms described are the signs of theophylline toxicity.
DIF: Cognitive Level: Analysis REF: Page 60N
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OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What
significant information would the nurse include?
a. Wrapping the infant snugly for rest periods
b. Positioning the infant prone for sleep
c. Sitting the infant up in an infant seat
d. Placing infants on their backs or sides for sleep
ANS: D
The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying
position on a firm mattress to prevent SIDS.
DIF: Cognitive Level: Comprehension REF: Page 619
OBJ: 17 TOP: Sudden Infant Death Syndrome
KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity
16. An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis?
a. Fatigue related to increased work of breathing
b. Ineffective breathing pattern related to airway inflammation and increased secretions
c. Risk for fluid volume deficit related to tachypnea and decreased oral intake
d. Fear and/or anxiety related to dyspnea and hospitalization
ANS: B
An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.
DIF: Cognitive Level: Analysis REF: Page 599
OBJ: 5 TOP: Respiratory Syncytial Virus (RSV)
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KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity
17. The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would
indicate the child is experiencing increased respiratory obstruction?
a. Restlessness
b. Tachycardia
c. Brassy cough
d. Expiratory wheezing
ANS: A
Restlessness is a primary sign of increased respiratory obstruction.
DIF: Cognitive Level: Analysis REF: Page 597
OBJ: 5 TOP: Acute Croup KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the
warning to rinse the mouth after inhaling the powder. What does this prevent?
a. Discoloration of tooth enamel
b. Halitosis
c. Irritation of oral membranes
d. Candidiasis
ANS: D
Inhalant powders can cause candidiasis (yeast) infection of the mouth.
DIF: Cognitive Level: Comprehension REF: Page 609
TOP: Candidiasis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: PharmNaUcR
olSoIgNicGaTl Bth.C
erOaM
pies
19. The nurse is caring for a 3-year-old who suffered a smoke inhalation injury. How long is this patient at the
highest risk for pulmonary edema after exposure?
a. 2 hours
b. 4 hours
c. 18 hours
d. 72 hours
ANS: D
Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure.
DIF: Cognitive Level: Comprehension REF: Page 601
TOP: Smoke Inhalation KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. Which is the most appropriate nursing action when planning care for a child with cystic fibrosis?
a. Provide chest physiotherapy before meals every day.
b. Assess weight monthly.
c. Administer pancrease with protein food at mealtime.
d. Ensure high-protein, high-calorie diet.
ANS: D
The maintenance of adequate nutrition is essential. The diet is high in protein and calories. Chest
physiotherapy should be done between meals. Pancreatic enzyme powder should be given with applesauce or
other nonstarch, nonfat, nonprotein food. Children with cystic fibrosis should be weighed daily.
DIF: Cognitive Level: Application REF: Page 615
TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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21. The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to
prevent this from happening with the child they are currently expecting. What will the nurse explain as the best
way to prevent BPD?
a. Maternal intake of folic acid
b. Exercise
c. Prevention of preterm birth
d. Provision of oxygen therapy to the newborn
ANS: C
Bronchopulmonary dysplasia (BPD) is a fibrosis, or thickening, of the alveolar walls and the bronchiolar
epithelium. It occurs in premature infants (less than 32 weeks) who have abnormal or arrested lung
development and receive ventilation and oxygen for more than 28 days to survive. Respiratory distress in the
newborn is the major reason why oxygen and ventilators are used for prolonged periods. The main cause of
respiratory distress in the newborn is prematurity. Therefore the prevention of preterm births is the best way to
prevent BPD.
DIF: Cognitive Level: Knowledge REF: Page 618
TOP: Bronchopulmonary Dysplasia KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
MULTIPLE RESPONSE
22. The nurse describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that
apply.)
a. Mouth breathing
b. Transverse nasal crease
c. Dark circles under the eyes
d. Productive cough
e. Reddened conjunctiva
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ANS: A, B, C, E
The allergic salute does not include a productive cough.
DIF: Cognitive Level: Comprehension REF: Page 604
OBJ: 9 TOP: Allergic Salute
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. The nurse would suggest the parents of an asthmatic child to encourage participation in which sport(s)?
(Select all that apply.)
a. Swimming
b. Gymnastics
c. Baseball
d. Cross-country skiing
e. Distance running
ANS: A, B, C
Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics.
Swimming, gymnastics, and baseball fit this criterion.
DIF: Cognitive Level: Comprehension REF: Page 609
TOP: Sports Activities Suitable for Asthmatics
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24. The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all that apply.)
a. Abdominal distention
b. Vomiting
c. Hiccoughing
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d. Jaundice
e. Absence of stool
ANS: A, B, E
Distended abdomen, vomiting, and absence of stool are the signs indicating meconium ileus in the newborn.
DIF: Cognitive Level: Comprehension REF: Page 603
TOP: Meconium Ileus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25. What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all
that apply.)
a. Inhale deeply through nose with mouth closed.
b. Make exhalation twice as long as inhalation.
c. Use medicated inhaler prior to performing breathing exercise.
d. Exhale through mouth as if whistling.
e. Exhale forcefully.
ANS: A, B, D
The technique requires that breath be inhaled through the nose and exhaled through pursed lips in a nonforcefu
manner. The exhalation should be twice as long as the inhalation.
DIF: Cognitive Level: Comprehension REF: Page 609
TOP: Pursed-Lip Breathing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement?
(Select all that apply.)
a. Maintain strict bed rest.
b. Consider age.
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c. Assess developmental level.
d. Implement light play activities.
e. Provide hypnotic medication as ordered.
ANS: B, C, D
Confinement to bed for a child does not always result in physical rest. In pediatrics, bed rest means providing
play therapy that promotes minimal activity. The nurse should consider the age and developmental level of the
child and the activity level involved in the play when designing appropriate activities and guiding parents in
the home care of their child.
DIF: Cognitive Level: Application REF: Page 595
TOP: Bed Rest KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
27. The school nurse suspects a first grade student has sinusitis. Which symptoms might lead the nurse to this
suspicion? (Select all that apply.)
a. Child reports tooth pain.
b. Severe wheezing is auscultated on inspiration.
c. Child reports, I have had a cold for 2 weeks.
d. Nurse observes periorbital swelling.
e. Halitosis is present.
ANS: A, C, D, E
The proximity of the sinus to the tooth roots often results in tooth pain when the sinus is infected. The
maxillary and ethmoid sinuses are most often involved in childhood sinusitis. Therefore the signs and
symptoms of sinusitis in children are different from those in adults, depending on the age of the child and
which sinus is fully developed. An acute sinusitis is suspected when an upper respiratory infection lasts longer
than 10 days, with a daytime cough. Halitosis is often present. Untreated sinusitis can lead to periorbital
cellulitis. Severe wheezing is not indicative of sinusitis.
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DIF: Cognitive Level: Comprehension REF: Page 597
TOP: Sinusitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms
exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.)
a. Harsh cough
b. Restlessness
c. Edematous epiglottis
d. Child insists on lying down
e. Drooling
ANS: B, C, E
H. influenzae type B and most often occurs in children 3 to 6 years of age. It can occur in any season. The
course is rapid and progressive. The onset of epiglottitis is abrupt, and the child presents with classic
symptoms. The child insists on sitting up, leans forward with the mouth open, and drools saliva because of the
difficulty in swallowing. The child appears wide-eyed, anxious, and restless, and he or she may emit a froglike
croaking sound on inspiration. Cough is absent. Inspection of the throat shows an enlarged, reddened
edematous epiglottis much like a beefy-red thumb. However, the examining tongue blade may trigger a
laryngospasm and result in sudden respiratory arrest.
DIF: Cognitive Level: Comprehension REF: Page 598
TOP: Epiglottitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. What will the nurse discourage when providing education to parents of a child with asthma? (Select all that
apply.)
a. Stuffed toys
b. Pet ownership
c. Gymnastics
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d. Basketball
e. Cotton blankets
ANS: A, D
Use of stuffed toys is discouraged due to potential allergens. Basketball might not be well tolerated because of
the constant physical exertion. Certain pets are encouraged, gymnasitics is usually well tolerated, and cotton
blankets are recommended for children with asthma.
DIF: Cognitive Level: Comprehension REF: Page 607
TOP: Asthma KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
COMPLETION
30. The nurse explains that the
signal the brainstem to increase respiration.
can sense the oxygen concentration in the blood and
ANS:
chemoreceptors
Chemoreceptors can sense the oxygen concentration of the blood and signal the brainstem to increase and
deepen respirations to keep an adequate supply of oxygen in the circulating volume.
DIF: Cognitive Level: Knowledge REF: Page 594
TOP: Chemoreceptors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the
nurse explains that routine immunizations will need to be delayed for
months.
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ANS:
9
After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral
medications affect the integrity of the immunizations.
DIF: Cognitive Level: Knowledge REF: Page 600
TOP: Respiratory Syncytial Virus (RSV)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
32. The nurse reviews Accolate and Zyflo, which are
of blocking the inflammatory response as well as providing bronchodilation.
; they are capable
ANS:
leukotriene modifiers
The leukotriene modifiers are capable of blocking the inflammatory response and can also provide
bronchodilation.
DIF: Cognitive Level: Knowledge REF: Page 607
OBJ: 12 TOP: Leukotriene Modifiers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33. Place the three stages of smoke inhalation injury in the correct order (first to last). Put a comma and space
between each answer choice (a, b, c, d, etc.)
a. Bronchopneumonia
b. Pulmonary insufficiency
c. Pulmonary edema
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ANS:
B, C, A
Smoke inhalation injury may cause carbon monoxide poisoning. Poisonous substances inhaled from burning
material may also cause pathological disturbance. There are three stages of inhalation injury:
1. Pulmonary insufficiency in the first 6 hours
2. Pulmonary edema from 6 to 72 hours
3. Bronchopneumonia after 72 hours, which may cause atelectasis
DIF: Cognitive Level: Knowledge REF: Page 601
TOP: Smoke Inhalation KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 26: The Child with a Cardiovascular Disorder
MULTIPLE CHOICE
1. What does the nurse explain that a ventricular septal defect will allow?
a. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
b. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
c. No shunting because of high pressure in the left ventricle
d. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
ANS: A
Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right
because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
DIF: Cognitive Level: Comprehension REF: Page 626
TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
a. A loud, harsh murmur with a systolic thrill
b. Cyanosis when crying
c. Blood pressure higher in the arms than in the legs
d. A machinery-like murmur
ANS: A
A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.
DIF: Cognitive Level: Comprehension REF: Page 626
TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: PhysiN
olUoR
giScIaNl G
ATdB
ap.CtaOtiM
on
3. What finding would the nurse expect when measuring blood pressure on all four extremities of a child with
coarctation of the aorta?
a. Blood pressure higher on the right side
b. Blood pressure higher on the left side
c. Blood pressure lower in the arms than in the legs
d. Blood pressure lower in the legs than in the arms
ANS: D
The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses
between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to
the coarctation.
DIF: Cognitive Level: Comprehension REF: Page 627
TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurses
best response?
a. Squatting increases the return of venous blood back to the heart.
b. Squatting decreases arterial blood flow away from the heart.
c. Squatting is a common resting position when a child is tachycardic.
d. Squatting increases the workload of the heart.
ANS: A
The squatting position allows the child to breathe more easily because systemic venous return is increased.
DIF: Cognitive Level: Comprehension REF: Page 627
TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the nurse understand
regarding why dyspnea occurs?
a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion.
b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia.
c. Blood is shunted past cardiac arteries, causing myocardial hypoxia.
d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the
heart.
ANS: A
When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.
DIF: Cognitive Level: Comprehension REF: Page 626
OBJ: 4 TOP: Congenital Heart Disease
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
a. Counting the apical rate for 30 seconds before administering the medication
b. Withholding a dose if the apical heart rate is less than 100 beats/min
c. Repeating a dose if the child vomits within 30 minutes of the previous dose
d. Checking respiratory rate and blood pressure before each dose
ANS: B
As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is
notified.
DIF: Cognitive Level: Application REF: Page 630
TOP: Congestive Heart Failure KEY: NursingNPUrR
ocSeIsNsGSTteBp.C
: IOmMplementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. A child develops carditis from rheumatic fever. Which areas of the heart are affected by carditis?
a. Coronary arteries
b. Heart muscle and the mitral valve
c. Aortic and pulmonic valves
d. Contractility of the ventricles
ANS: B
The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral
valve is frequently involved.
DIF: Cognitive Level: Knowledge REF: Page 632
TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. Which comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital
heart defect?
a. He is always hungry.
b. He tires out during feedings.
c. He is fussy for several hours every day.
d. He sleeps all the time.
ANS: B
Fatigue during feeding or activity is common to most infants with congenital cardiac problems.
DIF: Cognitive Level: Application REF: Page 629
OBJ: 3 TOP: Congenital Heart Disease
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How
does Kawasaki disease affect my childs heart and blood vessels? On what understanding is the nurses response
based?
a. Inflammation weakens blood vessels, leading to aneurysm.
b. Increased lipid levels lead to the development of atherosclerosis.
c. Untreated disease causes mitral valve stenosis.
d. Altered blood flow increases cardiac workload with resulting heart failure.
ANS: A
Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.
DIF: Cognitive Level: Comprehension REF: Page 635
TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes
cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?
a. If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.
b. If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.
c. If the baby turns blue, I will immediately put the baby upright in an infant seat.
d. If the baby turns blue, I will put the baby in supine position with his head elevated.
ANS: A
In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.
DIF: Cognitive Level: Application REF: Page 628
OBJ: 4 TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Evaluation
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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look
like that? On what understanding does the nurse base a response?
a. Clubbing occurs as a result of untreated congestive heart failure.
b. Clubbing occurs as a result of a left-to-right shunting of blood.
c. Clubbing occurs as a result of decreased cardiac output.
d. Clubbing occurs as a result of chronic hypoxia.
ANS: D
Clubbing of the fingers develops in response to chronic hypoxia.
DIF: Cognitive Level: Comprehension REF: Page 627
OBJ: 4 TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction
with this finding, would confirm a diagnosis of rheumatic fever?
a. Subcutaneous nodules and fever
b. Painful, tender joints and carditis
c. Erythema marginatum and arthralgia
d. Chorea and elevated sedimentation rate
ANS: B
The presence of two major Jones criteria would indicate a high probability of rheumatic fever.
DIF: Cognitive Level: Application REF: Page 632
OBJ: 6 TOP: Rheumatic Fever
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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. An infant with congestive heart failure is receiving digoxin (Lanoxin). What does the nurse recognize as a
sign of digoxin toxicity?
a. Restlessness
b. Decreased respiratory rate
c. Increased urinary output
d. Vomiting
ANS: D
Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a
sudden change in pulse.
DIF: Cognitive Level: Comprehension REF: Page 630
TOP: Heart Failure KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
14. Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood?
a. The patent ductus arteriosus
b. A ventricular septal defect
c. The closure of the foramen ovale
d. An atrial septal defect
ANS: D
Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation,
the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.
DIF: Cognitive Level: Knowledge REF: Page 628
TOP: Hypoplastic Left Heart Syndrome KEYN
:N
ssMStep: Planning
UuRrSsIin
NgGPTrBo.cCeO
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse
recognize that this indicates?
a. Seizure activity
b. Hypoxia
c. Sydenhams chorea
d. Decreasing level of consciousness
ANS: C
As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenhams chorea,
manifested by involuntary, purposeless movements of the limbs.
DIF: Cognitive Level: Knowledge REF: Page 632
TOP: Sydenhams Chorea KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. How long should a 4-year-old child recovering from rheumatic fever need to receive monthly injections of
penicillin G?
a. 1 year
b. 2 years
c. 5 years
d. 10 years
ANS: C
Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G
injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to prevent further
bouts of rheumatic fever.
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DIF: Cognitive Level: Knowledge REF: Page 633
TOP: Prophylaxis for Rheumatic Fever KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. What is accurate about the characteristics of high-density lipoproteins (HDLs)?
a. They have high amounts of triglycerides.
b. They have only small amounts of protein.
c. They have little cholesterol.
d. They aid in steroid production.
ANS: C
HDLs have low amounts of triglycerides, large amounts of proteins, low amount of cholesterol, and are
excreted via the liver. They have no role in the production of steroids.
DIF: Cognitive Level: Knowledge REF: Page 634
TOP: High-Density Lipoproteins KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. What should the school nurse recommend when encouraging a heart-healthy diet for a child with high
cholesterol?
a. A fat intake reduction of 5-10% of total calories
b. A fat intake reduction of 10-15% of total calories
c. A fat intake reduction of 15-20% of total calories
d. A fat intake reduction of 25-35% of total calories
ANS: D
For a child with increased cholesterol a fat reduction of 25-35% of total calories with less than 75 saturated fat
and less than 200 mg of cholesterol per day is advised.
DIF: Cognitive Level: Knowledge REF: PageN6U
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TOP: Heart-Healthy Diet KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. The nurse is planning a hypertension-prevention program. What should be the main focus of the nurse
when presenting information?
a. Pharmacological treatment
b. Surgical interventions available
c. Patient education
d. Reduction of aerobic exercise
ANS: C
The main focus of a hypertension-prevention program is patient education.
DIF: Cognitive Level: Knowledge REF: Page 634
TOP: Hypertension Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is structurally normal
and to localize a murmur. What diagnostic test does the nurse anticipate?
a. Barium swallow
b. Chest x-ray
c. Electrocardiogram
d. Echocardiogram
ANS: D
Echocardiography is a noninvasive procedure that localizes murmurs and determines if theheart is structurally
normal.
DIF: Cognitive Level: Knowledge REF: Page 625
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OBJ: N/A TOP: Diagnostic Tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
21. How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to
adapt for the childs weakness and fatigue? (Select all that apply.)
a. Feeding more frequently with smaller feedings
b. Using a soft nipple with enlarged holes
c. Holding and cuddling the child during feeding
d. Substituting glucose water for formula
e. Offering high-caloric formula
ANS: A, B, C, E
Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft,
large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to
nurse if he or she is held.
DIF: Cognitive Level: Application REF: Page 630
TOP: Feeding Infant with CHF KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select the four that
apply.)
a. Hypertrophied right ventricle
b. Patent ductus arteriosus
c. Ventral septal defect
d. Narrowing of pulmonary artery
e. Dextroposition of aorta
NURSINGTB.COM
ANS: A, B, D, E
The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus,
stenosis of pulmonary artery, and dextroposition of the aorta.
DIF: Cognitive Level: Knowledge REF: Page 627
TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a
paroxysmal hypercyanotic episode? (Select all that apply.)
a. Spontaneous cyanosis
b. Dyspnea
c. Weakness
d. Dry cough
e. Syncope
ANS: A, B, C, E
Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea,
weakness, and syncope.
DIF: Cognitive Level: Comprehension REF: Page 627
TOP: Tet Spells KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply.)
a. Atrial septal defects (ASDs)
b. Tetralogy of Fallot
c. Dextroposition of aorta
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d. Patent ductus arteriosus
e. Ventricular septal defects (VSDs)
ANS: A, D, E
The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus
arteriosus.
DIF: Cognitive Level: Comprehension REF: Page 628
TOP: Congenital Heart Defects KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. A 16-year-old patient is diagnosed with primary hypertension. What risk factors does the nurse mention
when providing education on this diagnosis to the patient and his family? (Select all that apply.)
a. Heredity
b. Stress
c. Congenital defect
d. Obesity
e. Poor diet
ANS: A, B, D, E
Primary, or essential, hypertension implies that no known underlying disease is present. Nevertheless, heredity,
obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension.
DIF: Cognitive Level: Comprehension REF: Page 625
TOP: Primary Hypertension KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
26. The nurse takes into consideration that theNm
mTmBo.C
n OcoMngenital heart defect is the
UoRsSt IcNoG
defect.
ANS:
ventricular septal
VSDs are the most common congenital heart defect.
DIF: Cognitive Level: Knowledge REF: Page 633
TOP: VSD KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. The nurse explains that the difference between the systolic blood pressure reading and the diastolic blood
pressure reading is called the
.
ANS:
pulse pressure
The pulse pressure is the difference between the diastolic pressure and the systolic pressure.
DIF: Cognitive Level: Knowledge REF: Page 626
TOP: Pulse Pressure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. Because the diagnosis of rheumatic fever is difficult, an aid used to identify the presence of rheumatic feve
is the
.
ANS:
Jones criteria
The Jones criteria identify a cluster of symptoms and divide them into major criteria and minor criteria. The
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formula for making the diagnosis of rheumatic fever is to identify two major criteria in the patient, or one
major and two minor criteria.
DIF: Cognitive Level: Knowledge REF: Page 627
TOP: Jones Criteria KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
29.
is designed to serve the metabolic needs during intrauterine life and also to
permit safe transition to life outside the womb.
ANS:
Fetal circulation
Fetal circulation is designed to serve the metabolic needs during intrauterine life and also to permit safe
transition to life outside the womb.
DIF: Cognitive Level: Knowledge REF: Page 632
TOP: Fetal Circulation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
30. Systemic blood pressure increases with age and is correlated with
childhood and adolescence.
and
throughout
ANS:
height; weight
Systemic blood pressure increases with age and is correlated with height and weight throughout childhood and
adolescence. Significant hypertension is considered when measurements are persistently at or above the 95th
percentile for the patients age and sex.
DIF: Cognitive Level: Knowledge REF: PageN6U
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TOP: Hypertension KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
31.
is a systemic disease involving the joints, heart, central nervous system (CNS), skin,
and subcutaneous tissues. It belongs to a group of disorders known as collagen diseases.
ANS:
Rheumatic fever (RF)
Rheumatic fever (RF) is a systemic disease involving the joints, heart, central nervous system (CNS), skin, and
subcutaneous tissues. It belongs to a group of disorders known as collagen diseases
DIF: Cognitive Level: Knowledge REF: Page 631
TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 27: The Child with a Condition of the Blood, Blood-Forming
Organs, or Lymphatic System
MULTIPLE CHOICE
1. The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition. What food
would the nurse emphasize as being a rich source of iron?
a. An egg white
b. Cream of Wheat
c. A banana
d. A carrot
ANS: B
Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried
fruits, beans, nuts, and whole-grain breads.
DIF: Cognitive Level: Comprehension REF: Page 640
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. Which statement by a mother may indicate a cause for her 9-month-olds iron deficiency anemia?
a. Formula is so expensive. We switched to regular milk right away.
b. She almost never drinks water.
c. She doesnt really like peaches or pears, so we stick to bananas for fruit.
d. I give her a piece of bread now and then. She likes to chew on it.
ANS: A
Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life.
NURSINGTB.COM
e 640 REF: Pag
DIF: Cognitive Level: Application
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric
unit?
a. With milk
b. With orange juice
c. With water
d. On a full stomach
ANS: B
Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.
DIF: Cognitive Level: Application REF: Page 640
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. What is the result of a deficiency of factor IX?
a. Thalassemia
b. Idiopathic thrombocytopenic purpura
c. Hemophilia A
d. Christmas disease
ANS: D
Christmas disease, or hemophilia B, is caused by the deficiency of factor IX.
DIF: Cognitive Level: Knowledge REF: Page 646
TOP: Christmas Disease KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a
teaching plan about home care?
a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity.
b. Childrens aspirin in lowered doses may be given for joint discomfort.
c. A firm, dry toothbrush should be used to clean teeth at least twice a day.
d. Do not permit interactive play with other children.
ANS: A
When bleeding occurs, the traditional approach is to follow RICErest, ice, compression, and elevation.
DIF: Cognitive Level: Application REF: Page 646
TOP: Hemophilia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. What will the nurse teach the parents of a child with a low platelet count to avoid?
a. Ibuprofen
b. Aspirin
c. Caffeine
d. Prednisone
ANS: B
Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding.
DIF: Cognitive Level: Application REF: Page 647
TOP: Leukemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. What should the nurse closely assess in a chNilUdRrSecIN
eiG
vT
inBg.C
a OtrM
ansfusion?
a. Fever
b. Lethargy
c. Jaundice
d. Bradycardia
ANS: A
The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching,
fever, rash, headache, and back pain.
DIF: Cognitive Level: Comprehension REF: Page 650
OBJ: 16 TOP: Blood Transfusion
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
8. On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. What is
the priority nursing intervention?
a. Assessing neurological status
b. Inserting an intravenous line
c. Monitoring vital signs during platelet transfusions
d. Providing family education about how to prevent bleeding
ANS: A
When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are
therefore a priority of care.
DIF: Cognitive Level: Application REF: Page 647
TOP: Leukemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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9. An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been
found to be involved, including cervical and inguinal nodes. Which disease stage is this?
a. I
b. II
c. III
d. IV
ANS: C
Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage III Hodgkins
disease.
DIF: Cognitive Level: Application REF: Page 651
OBJ: N/A TOP: Hodgkins Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe
abdominal pain. Which type of crisis is the child most likely experiencing?
a. Aplastic
b. Hyperhemolytic
c. Vaso-occlusive
d. Splenic sequestration
ANS: C
Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and
some degrees of vasospasm.
DIF: Cognitive Level: Application REF: Page 642
OBJ: 8 TOP: Sickle Cell Disease
KEY: Nursing Process Step: Data Collection NURSINGTB.COM
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. Which statement made by a parent indicates an understanding of health maintenance of a child with sickle
cell disease?
a. I should give my child a daily iron supplement.
b. It is important for my child to drink plenty of fluids.
c. He needs to wear protective equipment if he plays contact sports.
d. He shouldnt receive any immunizations until he is older.
ANS: B
Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with
sickle cell disease.
DIF: Cognitive Level: Application REF: Page 644
TOP: Sickle Cell Disease KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12. A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait.
How can the nurse best explain the childrens risk of inheriting this disease?
a. Every fourth child will have the disease; two others will be carriers.
b. All of their children will be carriers, just as they are.
c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier.
d. The risk levels of their children cannot be determined by this information.
ANS: C
The sickle cell gene is inherited from both parents; therefore each offspring has a one in four chance of
inheriting the disease.
DIF: Cognitive Level: Analysis REF: Page 643
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OBJ: 7 TOP: Sickle Cell Disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13. A child with thalassemia major receives blood transfusions frequently. What is a complication of repeated
blood transfusions?
a. Hemarthrosis
b. Hematuria
c. Hemoptysis
d. Hemosiderosis
ANS: D
As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues.
DIF: Cognitive Level: Comprehension REF: Page 645
TOP: Thalassemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction
of immature white blood cells in the bone marrow?
a. Decreased T-cell production
b. Decreased hemoglobin
c. Increased blood clotting
d. Increased susceptibility to infection
ANS: D
An overproduction of immature white blood cells increases the childs susceptibility to infection.
DIF: Cognitive Level: Comprehension REF: Page 648
TOP: Leukemia KEY: Nursing Process Step: N
DU
atRaSCIN
olG
leTcB
ti.oCnOM
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. The child receiving a transfusion complains of back pain and itching. What is the best initial action by the
nurse?
a. Notify the charge nurse.
b. Disconnect intravenous lines immediately.
c. Give diphenhydramine (Benadryl).
d. Clamp off blood and keep line open with normal saline.
ANS: D
If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with
normal saline, and notify the charge nurse.
DIF: Cognitive Level: Application REF: Page 650
TOP: Blood Transfusion KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
16. What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy?
a. Use commercial mouthwash.
b. Clean teeth with a soft toothbrush.
c. Avoid use of a Water-Pik.
d. Inspect the mouth weekly for ulcerations.
ANS: B
A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and
infection. Commercial mouthwashes may kill oral flora that combat infection. Water-Pik is useful for
toughening gums.
DIF: Cognitive Level: Application REF: Page 650
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TOP: Leukemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. A 6-year-old with leukemia asks, Who will take care of me in heaven? What is the best response by the
nurse?
a. Who do you think will take care of you?
b. Your grandparents and God will take care of you.
c. Your mom will know more about that than I do.
d. Why are you asking me that?
ANS: A
This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed
responses shut off communication. The asking of a why question is not therapeutic as it calls for justification.
DIF: Cognitive Level: Application REF: Page 650
TOP: Leukemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18. The nurse is dealing with a preschool-age child with a life-threatening illness. What should the nurse
remember the childs concept of death is at this age?
a. That it is final
b. Only a fear of separation from her parents
c. That a person becomes alive again soon after death
d. An understanding based on simple logic
ANS: C
The preschooler views death as reversible and temporary.
DIF: Cognitive Level: Comprehension REF: Page 656
OBJ: 19 TOP: Nursing Care of the Dying ChiN
ldURSINGTB.COM
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
19. The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his
extremities. Which lab value is consistent with these symptoms?
a. Platelet count of 25,000/mm3
b. Hemoglobin level of 8 g/dL
c. Hematocrit level of 36%
d. Leukocyte count of 14,000/mm3
ANS: A
The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased
bleeding potential.
DIF: Cognitive Level: Analysis REF: Page 647
TOP: Idiopathic Thrombocytopenic Purpura
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly
distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings
suggest?
a. Peripheral neuropathy
b. Stomatitis
c. Myelosuppression
d. Hemorrhage
ANS: A
Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the
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bowel.
DIF: Cognitive Level: Analysis REF: Page 650
TOP: Leukemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
21. The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. What is
the most appropriate nursing response to this comment?
a. I understand how you must feel.
b. You shouldnt feel that way.
c. Is this the strongest feeling youve had today?
d. Tell me whats got you scared.
ANS: D
The nurse should encourage the adolescent to express her feelings and concerns.
DIF: Cognitive Level: Application REF: Page 656
TOP: Adolescent with CancerFear of Death
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22. The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is
the priority nursing diagnosis for this child?
a. Risk for infection
b. Risk for hemorrhage
c. Altered skin integrity
d. Disturbance in body image
ANS: A
The child with neutropenia is at risk for infectN
ioUnR
. SINGTB.COM
DIF: Cognitive Level: Application REF: Page 649
OBJ: 15 TOP: Chemotherapy: Neutropenia
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
23. What important focus of nursing care for the dying child and the family should the nurse implement?
a. Nursing care should be organized to minimize contact with the child.
b. Adequate oral intake is crucial to the dying child.
c. Families should be made aware that hearing is the last sense to stop functioning before death.
d. It is best for the family if the nursing staff provides all of the childs care.
ANS: C
Hearing is intact even when there is a loss of consciousness.
DIF: Cognitive Level: Analysis REF: Page 656
TOP: Dying Child KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. The nurse is presenting information on the congentital disorder of hemophilia A. What fact will the nurse
include?
a. It is seen in males and females equally.
b. It is transmitted by symptom-free females.
c. It is a sex-linked dominant trait.
d. It is a defective gene located on the Y chromosome.
ANS: B
Hemophilia A affects mostly males who received the sex-linked recessive trait from a symptom-free female.
The defective gene is on the X chromosome.
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DIF: Cognitive Level: Comprehension REF: Page 646
TOP: Hemophilia A KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this disorder
goes untreated?
a. Hemorrhage
b. Heart failure
c. Infection
d. Pulmonary embolism
ANS: B
Untreated iron deficiency anemias progress slowly, and in severe cases the heart muscle becomes too weak to
function. If this happens, heart failure follows.
DIF: Cognitive Level: Comprehension REF: Page 640
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
26. The nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to
bleeding? (Select all that apply.)
a. Petichiae
b. Purpura
c. Ecchymosis
d. Hematoma
e. Lymphadenopathy
ANS: A, B, C, D
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The reduction or destruction of platelets in the body interferes with the clotting mechanism. Skin lesions that
are common to these disorders include petechiae, a bluish, nonblanching, pinpoint-sized lesion; purpura,
groups of adjoining petechiae; ecchymosis, an isolated bluish lesion larger than a petechia; and hematoma, a
raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or
disease.
DIF: Cognitive Level: Comprehension REF: Page 647
TOP: Manifestations of Bleeding KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care?
(Select all that apply.)
a. She will feel less neglected by the parents.
b. She can make amends for past hostilities to her brother.
c. She will feel increased helplessness.
d. She can express her feelings through care.
e. She can experience being supportive of her parents and brother.
ANS: A, B, D, E
All options are potential benefits to including the sibling in the care of a dying child except increased
helplessness. She would feel less helpless.
DIF: Cognitive Level: Comprehension REF: Page 655
OBJ: 21 | 25 TOP: Siblings KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28. What should be included in the nursing care of a 12-year-old child receiving radiation therapy for
Hodgkins disease? (Select all that apply.)
a. Application of sunblock
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b. Appetite stimulation
c. Conservation of energy
d. Provision for expressions of anger
e. Preparation for premature sexual development
ANS: A, B, C, D
Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and
anger in many young patients. Radiation delays the development of secondary sex characteristics and menses.
DIF: Cognitive Level: Application REF: Page 651
TOP: Effects of Radiation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. What are the classic symptoms of thalassemia major (Cooleys anemia)? (Select all that apply.)
a. Hepatomegaly
b. Jaundice
c. Protruding teeth
d. Pathological fractures
e. Renal failure
ANS: A, B, C, D
All of the options are classic signs of thalassemia major except renal failure.
DIF: Cognitive Level: Comprehension REF: Page 645
TOP: Thalassemia Major KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. How has synthetic recombinant antihemophilic factor improved the management of hemophilia? (Select all
that apply.)
a. Eliminates the need for frequent transfusionNs URSINGTB.COM
b. Can be administered by family at home
c. Prevents hemorrhage
d. Reduces cost of care of the hemophiliac
e. Reduces risk of HIV and hepatitis A and B transmission
ANS: A, B, D, E
The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not
necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly
reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent
hemorrhage; it makes hemorrhage manageable.
DIF: Cognitive Level: Comprehension REF: Page 646
TOP: Hemophilia A KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
31. The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of
the childs care? (Select all that apply.)
a. Using a support group
b. Stimulating appetite
c. Maintaining adequate hydration
d. Continuing with scheduled immunizations
e. Reporting exposure to infectious diseases
ANS: A, B, C, E
Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is
anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the
drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will
not allow the antibody response needed for immunization.
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DIF: Cognitive Level: Analysis REF: Page 650
OBJ: 15 | 21 TOP: Chemotherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
32. The nurse explains that the COPP medical regimen for the treatment of Hodgkins disease uses a
combination of which drugs? (Select all that apply.)
a. Vincristine
b. Cyclophosphamide
c. Methotrexate
d. Prednisone
e. Procarbazine hydrochloride
dont think we need to know this
ANS: A, B, D, E
The COPP medical regimen includes the combination of cyclophosphamide, vincristine (Oncovin), prednisone
and procarbazine hydrochloride.
DIF: Cognitive Level: Knowledge REF: Page 651
TOP: COPP KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33. A school-aged child is living with a chronic disease process. How would the nurse anticipate chronic
illness will effect growth and development? (Select all that apply.)
a. Delayed bonding with parents
b. Delayed toilet training
c. Impaired sense of belonging
d. Decreased feelings of independence
e. Impaired speech development
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ANS: C, D
A school-age child is in the stage of industry versus inferiority. A chronic illness might experience loss of
grade level in school because of illness and inability to participate or compete can lead to sense of inferiority.
Sense of independence and accomplishment can be lost. Being different from peers may impede childs sense
of belonging.
DIF: Cognitive Level: Comprehension REF: Page 654
TOP: Chronic Illness/Growth and Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Grief and Loss
COMPLETION
34. The nurse shows slides of red blood cells from a child with sickle cell disease, noting that in addition to
their sickle shape, the cells contain the abnormal element of
.
ANS:
hemoglobin S
Hemoglobin S is the abnormal hemoglobin that makes red blood cells fragile and causes the walls of the cells
to collapse, giving them the characteristic sickle shape.
DIF: Cognitive Level: Knowledge REF: Page 642
TOP: Sickle Cell Disease KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35. The nurse confirms that sickle cell trait can be distinguished from sickle cell disease by a lab test called
.
ANS:
dont think we know this
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electrophoresis
The hemoglobin electrophoresis is a blood test to check for different types of hemoglobin in the blood.
Hemoglobin is the substance in red blood cells that carries oxygen. Electrophoresis uses an electrical current to
separate normal and abnormal types of hemoglobin in the blood. Hemoglobin types have different electrical
charges and move at different speeds. The amount of each hemoglobin type in the current is measured. An
abnormal amount of normal hemoglobin or an abnormal type of hemoglobin in the blood may mean that a
disease is present. A person with sickle cell disease has abnormal hemoglobin S cells.
DIF: Cognitive Level: Knowledge REF: Page 642
TOP: Electrophoresis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36. To prevent
transfusion through a central line.
, the nurse warms the blood that is to be given as a
dont think we need this
ANS:
cardiac arrhythmias
Cold blood entering the heart via a central line can trigger an irregular heartbeat.
DIF: Cognitive Level: Comprehension REF: Page 650
OBJ: 16 TOP: Blood Transfusion
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
37. The rate of RBC production is regulated by
ANS:
erythropoietin
.
dont need to know this
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Erythropoietin is a glycoprotein hormone that controls erythropoiesis or red blood cell production.
DIF: Cognitive Level: Knowledge REF: Page 638
TOP: Components of Blood KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
38. Place the stages of dying in the usual order as detailed by Kbler-Ross (1975). Put a comma and space
between each answer choice (a, b, c, d, etc.)
a. Bargaining
b. Acceptance
c. Denial
d. Anger
e. Reaching out to help others
f. Depression
ANS:
C, D, A, F, B, E
The stages of dying as detailed by Kbler-Ross (1975)denial, anger, bargaining, depression, acceptance, and
reaching out to help otherscan be applied to parents and siblings as well as to the sick child. (Nurses may also
respond with similar feelings.) It is important to accept and support each participant at whatever stage has been
reached and to refrain from directing progress.
DIF: Cognitive Level: Comprehension REF: Page 656
TOP: Stages of Dying KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: End of Life Concepts
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Chapter 28: The Child with a Gastrointestinal Condition
MULTIPLE CHOICE
1. Which finding in a newborn is suggestive of tracheoesophageal fistula?
a. Failure to pass meconium in 24 hours
b. Choking on the first feeding
c. Palpable mass in the sternal area
d. Visible peristalsis across abdomen
ANS: B
After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is
introduced.
DIF: Cognitive Level: Comprehension REF: Page 660
TOP: Esophageal Atresia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. A child is brought to the pediatric clinic because he has been vomiting for the past 2 days. What acid-base
imbalance would the nurse expect to occur from this persistent vomiting?
a. Hyperkalemia
b. Hypernatremia
c. Acidosis
d. Alkalosis
ANS: D
Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting. This results in
alkalosis.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS6I6N6GTB.COM
OBJ: 9 TOP: Acid-Base Balance
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. On the second day of hospitalization for a 3-month-old brought in for treatment for gastroenteritis, the nurse
makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment?
a. Weight loss of 4 ounces
b. Dry mucous membranes
c. Decreased skin turgor
d. Depressed fontanelle
ANS: A
Weight loss is the most significant indicator of dehydration because an infants weight comprises 77% water.
DIF: Cognitive Level: Application REF: Page 672
OBJ: 9 TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Why are rapid respirations a possible cause of dehydration?
a. They prevent the child from drinking.
b. They increase circulation, thus increasing urine production.
c. They cause evaporation of fluid on the mucous membranes.
d. They often lead to vomiting.
ANS: C
Rapid respirations cause increased insensible fluid loss.
DIF: Cognitive Level: Comprehension REF: Page 672
TOP: Dehydration KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux?
a. Position the infant in the crib on his or her abdomen, with the head elevated.
b. Administer medication as ordered to stimulate the pyloric sphincter.
c. Give thin rice cereal with formula before feeding solid foods.
d. Place the infant in an infant seat after feedings.
ANS: A
After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure.
DIF: Cognitive Level: Application REF: Page 667
TOP: Gastroesophageal Reflux KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. The nurse is interviewing parents of an infant with pyloric stenosis. What would the nurse expect the parents
to report?
a. Diarrhea
b. Projectile vomiting
c. Poor appetite
d. Constipation
ANS: B
Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is
described as projectile vomiting.
DIF: Cognitive Level: Comprehension REF: Page 661
TOP: Pyloric Stenosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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7. A mother reports that her child has been scratching the anal area and complaining of itching. What does the
nurse suspect based on this information?
a. Pinworms
b. Giardiasis
c. Ringworm
d. Roundworm
ANS: A
With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of
itchiness. The other choices do not cause this reaction.
DIF: Cognitive Level: Application REF: Page 678
TOP: Worms KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. The nurse is teaching a parent about pyrvinium (Povan). What would be included in regard to potential side
effects?
a. Diarrhea
b. Skin rash
c. Red stool
d. Metallic taste
ANS: C
The nurse should advise parents that pyrvinium stains clothing and turns stools red.
DIF: Cognitive Level: Knowledge REF: Page 678
TOP: Worms KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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9. What instruction will the nurse give to parents about preventing the spread and reinfection of pinworms?
a. Keep childrens nails short.
b. Dress child in loose-fitting underwear.
c. Clean the bathroom with bleach solution.
d. Wash bed linens in cold water.
ANS: A
One intervention to prevent the further spread of pinworms is to keep the childs fingernails short. Pinworms
are not spread from person to person.
DIF: Cognitive Level: Comprehension REF: Page 678
TOP: Worms KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. A mother reports that her 2-year-old child experiences constipation frequently. Which food would the
nurse recommend to include in the childs diet?
a. Cooked vegetables
b. Pretzels
c. Whole-grain cereal
d. Yogurt
ANS: C
Dietary modifications for constipation include eating more high-roughage foods such as whole-grain breads
and cereals.
DIF: Cognitive Level: Comprehension REF: Page 670
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. What description of a childs stool characteNriUstRicSIlN
eaGdT
s Bth.C
eO
nuMrse to suspect intussusception?
a. Currant jelly
b. Black and tarry
c. Green liquid
d. Greasy and foul-smelling
ANS: A
Bowel movements of blood and mucus that contain no feces (currant jelly stools) are common about 12 hours
after the onset of the obstruction.
DIF: Cognitive Level: Comprehension REF: Page 665
TOP: Intussusception KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. What is the treatment of choice for a child with intussusception?
a. A barium enema
b. Immediate surgery
c. IV fluids until the spasms subside
d. Gastric lavage
ANS: A
A barium enema is the treatment of choice for intussusception because the passage of the barium frequently
un-telescopes the bowel. Surgery is scheduled only if reduction is not achieved.
DIF: Cognitive Level: Knowledge REF: Page 665
TOP: Intussusception KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13. Parents ask the nurse how their infant developed a Meckels diverticulum. What condition, will the nurse
explain, is present causing this diagnosis?
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a. The yolk sac remains connected to the intestine.
b. There is inflammation of the ileocecal valve.
c. A pouch forms when the vitelline duct fails to disappear.
d. There is a weakness in the abdominal wall.
ANS: C
If the vitelline duct fails to disappear completely after birth, a blind pouch may form.
DIF: Cognitive Level: Knowledge REF: Page 665
TOP: Meckels Diverticulum KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. An infant is admitted to the hospital with severe isotonic dehydration. For what is this child at the highest
risk?
a. Metabolic alkalosis
b. Hypocalcemia
c. Sepsis
d. Shock
ANS: D
Shock is the greatest threat to life in isotonic dehydration.
DIF: Cognitive Level: Comprehension REF: Page 673
TOP: Dehydration KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. A child is brought to the emergency department because he ingested an unknown quantity of
acetaminophen (Tylenol). What does the nurse expect this child to receive following gastric lavage?
a. Activated charcoal
b. N-acetylcysteine
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c. Vitamin K
d. Syrup of ipecac
ANS: B
Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen.
DIF: Cognitive Level: Comprehension REF: Page 679
TOP: Acetaminophen Poisoning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
16. The nurse is planning a parent education program about lead poisoning prevention. What will be included
regarding primary sources of lead in the community?
a. Increased lead content of air
b. Use of aluminum cookware
c. Deteriorating paint in older buildings
d. Inhaling smog
ANS: C
The primary source of lead is paint from old, deteriorating buildings.
DIF: Cognitive Level: Knowledge REF: Page 682
TOP: Lead Poisoning KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
17. A frightened mother calls the pediatricians office because her child swallowed dishwashing detergent.
What is the most appropriate action?
a. Induce vomiting by giving the child syrup of ipecac.
b. Take the child to the local emergency department.
c. Give the child activated charcoal mixed with juice.
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d. Give the child milk to soothe affected mucous membranes.
ANS: B
Inducing vomiting is no longer recommended because it may pose additional problems. The child should be
taken immediately to the nearest emergency department along with the packaging of the ingested substance.
DIF: Cognitive Level: Application REF: Page 678
OBJ: 13 TOP: Poisoning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. A child has been diagnosed with ascariasis (roundworm). Which statement made by her mother that may
suggest a cause for her condition?
a. Ive been airing out the house on these nice breezy days.
b. My child often goes out to the garden and pulls up a carrot to eat.
c. She runs barefoot so much I have to wash her feet at least twice a day.
d. We just remodeled our bathroom at home.
ANS: B
The child can ingest roundworm eggs from contaminated soil.
DIF: Cognitive Level: Comprehension REF: Page 678
TOP: Worms KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. What does the nurse expect the appearance of the stools of a child with celiac disease to be?
a. Ribbon like
b. Hard, constipated
c. Bulky, frothy
d. Loose, foul-smelling
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ANS: C
Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption.
DIF: Cognitive Level: Comprehension REF: Page 663
TOP: Celiac Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the
nurse explain can be eaten with celiac disease?
a. Wheat
b. Oats
c. Barley
d. Rice
ANS: D
Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a
lifelong restriction of wheat, oats, barley, and rye.
DIF: Cognitive Level: Knowledge REF: Page 663
TOP: Celiac Disease KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis. What will be the
nursess priority goal of the infants care?
a. Prevent fluid and electrolyte imbalance.
b. Prevent nutritional deficiency.
c. Prevent skin breakdown.
d. Prevent malabsorption.
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ANS: A
The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance.
DIF: Cognitive Level: Application REF: Page 666
TOP: Gastroenteritis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification
would the nurse advise?
a. Soft foods with rice, bananas, toast, and applesauce
b. Small amounts of clear fluids such as gelatin
c. An oral rehydrating solution, such as Pedialyte
d. Chicken soup because it is high in sodium
ANS: C
An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel
movements.
DIF: Cognitive Level: Application REF: Page 668
TOP: Diarrhea KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. What would the nurse expect to find in a child admitted to the hospital for nonorganic failure to thrive?
a. Cry to be picked up
b. Be limp like a rag doll
c. Be responsive to cuddling
d. Weigh in the 10th percentile for age
ANS: B
Some children with failure to thrive have rag-N
doUllRlSim
nT
esBs.C
(hOyM
potonia) and appear wary of their caregivers.
INpG
DIF: Cognitive Level: Comprehension REF: Page 675
TOP: Failure to Thrive KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24. Which nursing interventions will be implemented for the mother of a 10-month-old infant with nonorganic
failure to thrive?
a. Pointing out errors that the nurse observes when the mother is caring for the infant
b. Discussing negative characteristics of the infant with the mother
c. Having the nurse provide as much of the infants care as possible
d. Teaching the mother about the developmental milestones to expect in the next few months
ANS: D
The nurse can increase parents knowledge of growth and development by providing anticipatory guidance
about normal developmental milestones.
DIF: Cognitive Level: Application REF: Page 675
OBJ: N/A TOP: Failure to Thrive
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25. Which statement by a mother may indicate a cause of her sons vitamin C deficiency?
a. We get our fruits from homemade preserves.
b. We use milk from our own goats.
c. We grow all our own vegetables.
d. Were not big meat eaters.
ANS: A
Vitamin C is destroyed by heat.
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DIF: Cognitive Level: Comprehension REF: Page 676
TOP: Scurvy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26. The nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush.
What will the nurse include?
a. Pour the prescribed amount into a nipple and have the infant suck the medication.
b. Squirt the prescribed dose into the back of the mouth and have the infant swallow.
c. Give the medication mixed with a small amount of juice in a bottle.
d. Use a sterile applicator to swab the medication on the oral mucosa.
ANS: D
An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab
it on the inside of the mouth.
DIF: Cognitive Level: Application REF: Page 677
TOP: Thrush KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
27. Why are infants more vulnerable to fluid and electrolyte imbalances than adults?
a. They have a smaller surface area than adults in proportion to body weight.
b. Water needs and losses per kilogram are lower than those for adults.
c. A greater percentage of body water in infants is extracellular.
d. Infants have a lower metabolic turnover of water.
ANS: C
A greater percentage of body water is contained in the extracellular compartment of children under 2 years of
age.
DIF: Cognitive Level: Knowledge REF: PageN6U
72RSINGTB.COM
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. An infant is admitted to the hospital with severe dehydration. Laboratory results show pH 7.32, PaCO2 40,
HCO3 21. How does the nurse interpret these values?
a. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis
ANS: A
A pH lower than 7.35 indicates acidosis. If the childs pH falls in the same line as the HCO3, the problem is
metabolic (see Table 27-4).
DIF: Cognitive Level: Analysis REF: Page 674
OBJ: 9 TOP: Fluid and Electrolyte Imbalance
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying. What is the
most appropriate nursing action?
a. Delay feeding the child for 6 hours.
b. Offer regular formula thinned with water.
c. Give small amounts of regular formula thickened with cereal.
d. Allow 1 ounce of glucose water at frequent intervals.
ANS: D
Small oral feedings of glucose water are given after recovery from anesthesia. Feedings are gradually increased
to larger amounts of regular formula.
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DIF: Cognitive Level: Application REF: Page 661
TOP: Postoperative Pyloric Stenosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
30. The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knows that the
child needs to consume how many milliliters of oral fluid to make up for the fluid loss?
a. 18
b. 36
c. 64
d. 81
ANS: D
The formula for oral fluid replacement is 10 mL/kg. 18 pounds = 8.1 kg 10 = 81 mL.
DIF: Cognitive Level: Analysis REF: Page 671
TOP: Oral Fluid Replacement KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. Which statement made by a parent alerts the nurse to the need for additional education about poison
prevention?
a. I keep the poison control center phone number easily accessible.
b. All medication is kept out of reach in a locked cabinet.
c. I keep a bottle of syrup of ipecac handy.
d. Our garden is free from marigolds.
ANS: C
Traditionally, syrup of ipecac was the treatment of choice to remove some types of poisons from a childs
system and parents were advised to keep a supply on hand in the home. However, the American Academy of
Pediatrics (AAP) revised this policy in 2003. Parents are now advised to call the poison control center and
bring the container of the substance ingested tN
oU
thReShIN
osGpT
itB
al.CeO
mM
ergency department as quickly as possible
because stomach lavage is rarely effective 1 hour or more after ingestion. Ipecac syrup should not be kept in
the home. Uncontrolled vomiting can cause serious complications.
DIF: Cognitive Level: Comprehension REF: Page 679
TOP: Poison Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
32. Which assessment would the nurse report to the physician immediately?
a. 2-month-old with a urine output of 150 mL in 24 hours
b. 3-year-old with a urine output of 650 mL in 24 hours
c. 8-year-old with a urine output of over 1000 mL in 24 hours
d. 14-year-old with a urine output of 800 mL in 24 hourse
DNTK
ANS: A
The urine output of a 2-month-old should be between 400 and 500 mL/24 hours.
DIF: Cognitive Level: Application REF: Page 673
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Adaptation: Physiological Integrity
MULTIPLE RESPONSE
33. What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select all that
apply.)
a. Give a formula thinned with water.
b. Burp the infant before and during feeding.
c. Give the feeding slowly.
d. Refeed if the infant vomits.
e. Position infant on left side after feeding.
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ANS: B, C, D
Children with pyloric stenosis are given formula thickened with cereal; the infant is burped before and during
feeding to get rid of any gas in the stomach; the infant is fed slowly and refed if vomiting occurs. The infant is
positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve.
DIF: Cognitive Level: Application REF: Page 661
TOP: Pyloric Stenosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34. What assessment(s) would lead a nurse to suspect Hirschsprungs disease in a 1-month-old infant? (Select
all that apply.)
a. Ribbon-like stools
b. Fever
c. Failure to thrive
d. Vomiting
e. Diminished peristalsis
ANS: A, B, C, D, E
All options are significant indicators of Hirschsprungs disease.
DIF: Cognitive Level: Comprehension REF: Page 664
TOP: Hirschsprungs Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
35. What sign(s) indicate(s) moderate dehydration? (Select all that apply.)
a. 10% weight loss
b. Dry mucous membranes
c. Normal anterior fontanel
d. Increased urinary output
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e. Lethargy
ANS: A, B, C
The child that is moderately dehydrated will have lost 10% of his body weight, will have dry mucous
membranes, normal (nonsunken) anterior fontanelle, decreased urine output, and will be irritable.
DIF: Cognitive Level: Comprehension REF: Page 673
OBJ: 9 TOP: Moderate Dehydration
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36. A child is brought into the ED with suspected appendicitis. What signs and symptoms does the nurse
expect to assess? (Select all that apply.)
a. Left lower quandrant pain
b. Guarding
c. Rebound tenderness
d. Decreased C-reactive protein
e. Pain on lifting thigh when supine
ANS: B, C, E
With appendicitis on examination, characteristic tenderness in the right lower quadrant known as McBurneys
point will occur. Other diagnostic signs include guarding (tightening of the abdominal muscles or rigidity of
the abdomen on palpation); rebound tenderness (pressing the RLQ with rapid release of pressure causes severe
pain); pain on lifting the thigh while in the supine position is caused by muscle irritation. C-reactive protein
levels will be increased after 12 hours if any infection is present.
DIF: Cognitive Level: Comprehension REF: Page 676
OBJ: 1 TOP: Appendicitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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37. Parents have adopted a child with the diagnosis of kwashiorkor. What is most likely to be observed when
assessing this child? (Select all that apply.)
a. Hyperactivity
b. White streak in hair
c. Edematous abdomen
d. Slowed growth
e. Thick, oily hair
ANS: B, C, D
Kwashiorkor means, in native dialect, the disease of the deposed baby when the next one is born, indicating
that the child no longer breastfeeds because a sibling is born and takes over the breast of the mother. Oral
intake then is deficient in protein. The child fails to grow normally. The muscles become weak and wasted.
There is edema of the abdomen that may become generalized. Diarrhea, skin infections, irritability, anorexia,
and vomiting may be present. The hair becomes thin and dry. Because protein is the basis of melanin, a
substance that provides color to hair, melanin becomes deficient. This is the reason the earliest sign of this
protein malnutrition is a white streak in the hair of the child (depigmentation). The child looks apathetic and
weak.
DIF: Cognitive Level: Comprehension REF: Page 676
TOP: Nutritional Deficiencies KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
38. The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for an infant with gastroenteritis,
recognizes that this confirms the
process that is part of this disease.
ANS:
inflammatory
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The ESR elevates in the presence of an inflammatory response.
DIF: Cognitive Level: Comprehension REF: Page 666
TOP: Gastroenteritis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
39. The nurse explains that because
for fluid replacement in a child who is dehydrated.
beverages cause diuresis, they are not good choices
ANS:
caffeinated
Cola or other caffeinated drinks cause diuresis and will further dehydrate an already dehydrated child.
DIF: Cognitive Level: Knowledge REF: Page 668
TOP: Dehydration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
40. The nurse explains that rickets, a deficiency disease that causes bony deformities, is caused by the
inadequate supply of vitamin
.
ANS:
D
Rickets is caused by a deficiency of vitamin D.
DIF: Cognitive Level: Knowledge REF: Page 676
TOP: Rickets KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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41. The nurse reminds parents of a child allergic to cows milk that they should avoid foods that list
as part of their contents.
ANS:
casein
Food labels that list casein contain cows milk.
DIF: Cognitive Level: Comprehension REF: Page 666
OBJ: 2 TOP: Casein KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
42. The nurse explains the medically accepted definition of constipation is fewer than
in a 2-week period.
bowel movements
ANS:
seven
The medically accepted definition of constipation is fewer than seven bowel movements in a 2-week period.
DIF: Cognitive Level: Knowledge REF: Page 670
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
43. Hernias are successfully repaired by the surgical operation called a
ANS:
herniorrhaphy
.
DNTK
Hernias are successfully repaired by the surgical operation called a herniorrhaphy. This is a relatively simple
procedure and is well tolerated by the child. MNoUstRcShIiNldGrT
enB.aCreOM
scheduled for procedures in same-day surgery
units. The benefits of this method are both economic and psychological.
DIF: Cognitive Level: Knowledge REF: Page 666
TOP: Hernias KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 29: The Child with a Genitourinary Condition
MULTIPLE CHOICE
1. The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection in the child.
Which statement made by the parent indicates a need for further teaching?
a. My daughter should wash and wipe the perineal area from front to back.
b. I am only going to have my daughter wear cotton underwear.
c. It is acceptable to take frequent bubble baths.
d. She needs to drink lots of fluids and void frequently.
ANS: C
Oils in bubble bath and similar products are known to irritate the urethra.
DIF: Cognitive Level: Comprehension REF: Page 692
OBJ: N/A TOP: Acute Urinary Tract Infection
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. When asked about correcting the hypospadias of a newborn, what does the nurse explain about this
condition?
a. No intervention is necessary as the defect will correct itself over time.
b. Surgical repair of the hypospadias is done before 18 months of age.
c. Corrective surgery is usually delayed until the preschool age.
d. Repairing the defect will increase the risk of testicular cancer.
ANS: B
Treatment of hypospadias consists of surgical repair and is usually performed before 18 months of age.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS6I9N0GTB.COM
TOP: Hypospadias KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. What is an initial sign of nephrosis that the nurse might note in a child?
a. Raspberry-like rash
b. Periorbital edema
c. Temperature elevation
d. Abdominal pain
ANS: B
The edema of nephrotic syndrome is generalized and not readily noticed, even by the parents, but an early sign
that can be assessed is periorbital edema.
DIF: Cognitive Level: Knowledge REF: Page 692
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What is it important to assess in a child receiving prednisone to treat nephrotic syndrome?
a. Infection
b. Urinary retention
c. Easy bruising
d. Hypoglycemia
ANS: A
Prednisone depresses the immune response and increases susceptibility to infection. Because steroids mask
signs of infection, the child must be assessed for more subtle symptoms of illness.
DIF: Cognitive Level: Comprehension REF: Page 694
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Physiological Integrity
5. During a physical assessment of a hospitalized 5-year-old, the nurse notes that the foreskin has been
retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis.
What action should the nurse implement?
a. Forcibly push the foreskin down over the head of the penis.
b. Place a warm compress on the penis.
c. Notify the charge nurse.
d. Wait a few hours and try again.
ANS: C
Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the
penis; this should be remedied immediately.
DIF: Cognitive Level: Application REF: Page 689
TOP: Paraphimosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined to bed. What is
the most appropriate nursing intervention for this child?
a. Providing activities for the child on restricted activity
b. Feeding the child a protein-restricted diet
c. Carefully handling edematous extremities
d. Observing the child for evidence of hypotension
ANS: A
Although children may feel well, activity is limited until hematuria resolves.
DIF: Cognitive Level: Application REF: Page 695
TOP: Acute Glomerulonephritis KEY: NursinN
gUPR
roScIeNsG
s TSB
te.pC:OPM
lanning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
7. Which urinary diversion procedure is the least damaging to the body image of the adolescent?
a. Urostomy
b. Ileal conduit
c. Nephrostomy
d. Suprapubic placement
ANS: B
The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external
appliance, as is needed with the other diversion methods.
DIF: Cognitive Level: Comprehension REF: Page 691
OBJ: 10 TOP: Obstructive UropathyUrinary Diversions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he needs to get
immunizations to enter kindergarten. What does the nurse clarify about receiving immunizations while on
prednisone?
a. Can interfere with the treatment for nephrosis
b. Require that the child have antibiotic coverage
c. Can be given in smaller, divided doses
d. Should be delayed
ANS: D
No vaccinations or immunizations should be administered while the disease is active and during
immunosuppressive therapy.
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DIF: Cognitive Level: Comprehension REF: Page 694
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
9. Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids. What
protocol can the nurse encourage to bring about diuresis?
a. Ibuprofen, an anti-inflammatory agent
b. Furosemide (Lasix), a diuretic
c. Ciprofloxacin (Cipro), an antibiotic
d. Cyclophosphamide (Cytoxan), an antisuppressant
ANS: D
A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have proven
ineffective.
DIF: Cognitive Level: Application REF: Page 694
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
10. What foods does the nurse recommend the child with acute glomerulonephritis avoid to prevent
hyperkalemia?
a. Dairy products
b. Whole-grain cereals
c. Organ meats
d. Bananas
ANS: D
Bananas are very high in potassium and should be avoided.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS6I9N5GTB.COM
TOP: AGN KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. Which physical assessment technique will the nurse omit when caring for a 2-year-old diagnosed with
Wilms tumor?
a. Performing range-of-motion exercises on lower extremities
b. Palpating the abdomen
c. Assessing for bowel sounds
d. Percussing ankle and knee reflexes
ANS: B
Palpation of the abdomen could disturb the tumor and cause the malignancy to spread.
DIF: Cognitive Level: Application REF: Page 696
OBJ: 8 TOP: Wilms Tumor
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. Parents are speaking with the urologist about their sons undescended testicle. Which statement by the
childs father causes the nurse to determine he understands the information presented?
a. An undescended testicle can reduce fertility.
b. The testicle usually descends spontaneously during the first month of life.
c. Surgical correction reduces the risk for testicular tumors.
d. The optimal time to surgically correct the condition is at diagnosis.
ANS: A
Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only
one testis is undescended.
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DIF: Cognitive Level: Application REF: Page 698
TOP: Cryptorchidism KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. A parent tells the nurse that her child is scheduled for an x-ray of the bladder and urethra that is done while
the child is urinating. What is this test known as?
a. Cystometrogram
b. Cystoscopy
c. Voiding cystourethrogram
d. Intravenous pyelogram
ANS: C
An x-ray examination of the bladder and urethra before and during micturition is called a voiding
cystourethrogram.
DIF: Cognitive Level: Comprehension REF: Page 692
TOP: Diagnostic Procedures KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
14. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the nurse recognize
these signs and symptoms indicate?
a. Urinary tract infection
b. Nephrotic syndrome
c. Acute glomerulonephritis
d. Vesicoureteral reflux
ANS: A
Urinary frequency and pain during micturition are symptoms of acute urinary tract infection.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS6I9N1GTB.COM
TOP: Acute Urinary Tract Infection KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. What is an appropriate intervention for the edematous child with reduced mobility related to nephrotic
syndrome?
a. Reach the child to minimize body movements.
b. Change the childs position frequently.
c. Keep the head of the childs bed flat.
d. Keep edematous areas moist and covered.
ANS: B
The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate
skin.
DIF: Cognitive Level: Application REF: Page 694
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16. Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of
discharge teaching?
a. I will make sure he gets his measles vaccine as soon as he gets home.
b. He can stop taking his medication next week.
c. I should check his urine for protein when he goes to the bathroom.
d. He should eat a low-protein diet for the next few weeks.
ANS: C
The parents should be instructed to keep a daily record of the childs urinary proteins.
DIF: Cognitive Level: Application REF: Page 692
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TOP: Nephrotic Syndrome KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the childs history,
what does the nurse recognize as the probable cause?
a. Recovery from German measles 2 months ago
b. Dysuria since the previous night
c. A history of allergy
d. A sore throat 2 weeks ago
ANS: D
Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergictype response that alters the effectiveness of the glomeruli.
DIF: Cognitive Level: Comprehension REF: Page 694
TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection. Which is the
best beverage for the nurse to recommend to keep urine acidic?
a. Milk
b. Grape juice
c. Apple juice
d. Orange juice
ANS: C
Juices such as apple or cranberry help maintain acidity of urine.
DIF: Cognitive Level: Comprehension REF: Page 693
OBJ: N/A TOP: Acute Urinary Tract InfectionNURSINGTB.COM
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down
there? What is the nurses best response?
a. They are going to fix you up down there.
b. They will move your testicle from your abdomen to your scrotum.
c. What do you think your doctor is going to do?
d. You shouldnt worry. Your doctor knows exactly what to do.
ANS: C
Encourage the patient to talk about what he knows and what feelings he has about the surgery. School-age
children have a fear of bodily harm.
DIF: Cognitive Level: Application REF: Page 698
TOP: Orchiopexy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
20. What will the nurse caution the parents of a child who has had a nephrectomy that he will have to avoid?
a. Contact sports
b. Horseback riding
c. Alcohol
d. Diuretic medications
ANS: A
Children who have only one kidney should avoid contact sports to prevent injury to that remaining organ.
DIF: Cognitive Level: Comprehension REF: Page 696
TOP: Postnephrectomy Instruction KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. The parents of a newborn are concerned that their sons scrotum is enlarged and swollen on one side. What
is the nurses best response?
a. It is very common in the newborn that one gonad is larger than the other.
b. Birth trauma caused bruising to the scrotum. It will reduce in size in a few days.
c. It is a collection of fluid that will most likely correct itself in a year.
d. The doctor will drain this collection of blood before your baby is discharged.
ANS: C
These signs are indicative of a hydrocele, a collection of fluid in the scrotum that usually corrects itself in a
year.
DIF: Cognitive Level: Comprehension REF: Page 697
TOP: Hydrocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. The nurse is providing information to parents of a child born with bilateral cryptorchidism. What
information is accurate to include?
a. This is the most common form.
b. Fertility will be unaffected.
c. Surgical intervention is not recommended.
d. An inguinal hernia may be present.
ANS: D
When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism. The unilateral
form is more common. Because the testes are warmer in the abdomen than in the scrotum, the sperm cells
begin to deteriorate. If both testes are affected, sterility results. Inguinal hernia often accompanies this
condition. Occasionally, a testis or the testes spontaneously descend during the first year of life. An operation
called an orchiopexy may be performed.
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DIF: Cognitive Level: Comprehension REF: Page 698
TOP: Cryptorchidism KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. An adolescent male is admitted to the ED with severe acute scrotal pain. When documenting medical
history the nurse notes cryptorchidism at birth. What diagnosis does the nurse expect?
a. Urinary tract infection
b. Nephrosis
c. Torsion
d. Phimosis
ANS: C
When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism. Acute scrotal
pain may indicate a testicular torsion (twisting), which necessitates immediate surgery to preserve testicular
function.
DIF: Cognitive Level: Comprehension REF: Page 698
TOP: Torsion KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
24. A 7-year-old child has a BUN of 25 mg/dL. What is the nurse aware this lab value might indicate? (Select
all that apply.)
a. Dehydration
b. Renal disease
c. Need for steroid therapy
d. Diabetes
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e. Pituitary malfunction
ANS: A, B, C
Increased BUN can indicate dehydration, renal disease, and/or need for steroid therapy.
DIF: Cognitive Level: Analysis REF: Page 689
OBJ: 3 TOP: Diagnostic Tests
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
25. What will the nurse caring for a newborn with exstrophy of the bladder include in the care? (Select all that
apply.)
a. Diaper infant tightly.
b. Protect skin around bladder.
c. Position infant on back.
d. Prepare for surgical closure.
e. Cover exposed bladder with shield.
ANS: B, C, D, E
The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is
constantly bathed with urine. These infants are diapered loosely, if at all. Surgical closure is done as quickly as
possible.
DIF: Cognitive Level: Application REF: Page 690
TOP: Exstrophy of the Bladder KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
26. The nurse caring for a child with nephrotic syndrome is alert to which classic symptoms of this disorder?
(Select all that apply.)
a. Proteinuria
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b. Grossly bloody urine
c. Hyperalbuminemia
d. Fatigue
e. Generalized edema
ANS: A, B, D, E
All options listed are those of nephrotic syndrome with the exception of hyperalbuminemia. The nephrotic
child has hypoalbuminemia, as most of the protein has been spilled in the urine.
DIF: Cognitive Level: Knowledge REF: Page 692
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27. The nurse is aware that genitourinary surgery is especially stressful for preschool children. What factor(s)
lend to this stress? (Select all that apply.)
a. They may perceive the treatment as punishment.
b. They are especially prone to separation anxiety.
c. They are sexually curious and developmentally fixated on their genitals.
d. They have a fear of castration.
e. They fear death.
ANS: A, B, C, D
All options, except fear of death, are especially stressful for preschool children undergoing genitourinary
surgery. Children in this age group do not have an understanding of the concept of death.
DIF: Cognitive Level: Comprehension REF: Page 698
TOP: Topic: Impact of Surgery on Preschoolers
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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28. What special considerations are related to long-term prednisone therapy in preschoolers? (Select all that
apply.)
a. Delayed immunization
b. Hypertension
c. Enlargement of the sex organs
d. Alteration in nutrition
e. Increased risk for infection
ANS: A, E
Delayed immunization and greater risk for infection are concerns relative to long-term prednisone therapy.
DIF: Cognitive Level: Comprehension REF: Page 694
TOP: Long-Term Prednisone Therapy KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
29. The nurse explains that the device that measures the pressure and volume of the urine stream is called the
.
ANS:
uroflowmeter
The device that specifically measures the dynamics of micturition is the uroflowmeter.
DIF: Cognitive Level: Knowledge REF: Page 688
TOP: Uroflowmeter KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30. The nurse uses a diagram to show how the
, the working unit of the kidney, filters and
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regulates fluids.
ANS:
nephron
The nephron is the working unit of the kidney that filters and regulates fluids in the body. There are roughly 1
million nephrons in each kidney.
DIF: Cognitive Level: Comprehension REF: Page 686
TOP: Nephron KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. When a childs ureter becomes completely obstructed from scarring, the nurse explains that urinary
diversion may be necessary to prevent the reflux back into the renal pelvis from causing
.
ANS:
hydronephrosis
Hydronephrosis occurs when the urine is unable to pass through the ureter into the bladder; the urine refluxes
back into the renal pelvis, causing dilation and swelling of the kidney.
DIF: Cognitive Level: Comprehension REF: Page 690
TOP: Hydronephrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32. The strong urge to void, often despite the inability to do so, is known as
ANS:
urgency
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Urgency is the term that describes the strong urge to void, often despite the inability to do so.
DIF: Cognitive Level: Knowledge REF: Page 689
TOP: Urgency KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33. The nurse is measuring ouput on an infant on the pediatric unit. When weighing the diaper and subtracting
the weight of the dry diaper, the nurse records 30 grams and documents this as
mL.
ANS:
30
Diapers may be weighed on a gram scale before application and after removal (1 g = 1 mL).
DIF: Cognitive Level: Analysis REF: Page 694
TOP: Urinary Output KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques
34.
is a narrowing of the preputial opening of the foreskin, which prevents the foreskin
from being retracted over the penis.
ANS:
Phimosis
Phimosis is a narrowing of the preputial opening of the foreskin, which prevents the foreskin from being
retracted over the penis.
DIF: Cognitive Level: Knowledge REF: Page 689
TOP: Phimosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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Chapter 30: The Child with a Skin Condition
MULTIPLE CHOICE
1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month-old. How is
infant skin different from adult skin?
a. Less perfusion
b. Greater moisture
c. More perspiration
d. Greater absorption
ANS: D
The childs skin has a dramatically greater ability to absorb than does that of the adult.
DIF: Cognitive Level: Comprehension REF: Page 700
OBJ: 2 TOP: Skin Comparison
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. What risk is increased with children who have been diagnosed with infantile eczema?
a. Pneumonia
b. Acne
c. Sun sensitivity
d. Asthma
ANS: D
Some children with eczema also develop asthma and hay fevertype allergies.
DIF: Cognitive Level: Knowledge REF: Page 705
TOP: Infantile Eczema KEY: Nursing ProcessNSUtR
epS:IN
PlGaT
nnBi.nCgOM
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What is the appropriate technique for the application of a topical treatment for a child with eczema?
a. Apply skin lotions in a circular motion.
b. Apply prescribed ointments with a gloved hand.
c. Apply as much and as frequently as relieves the symptoms.
d. Choose lanolin-based ointments.
ANS: B
The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes.
Lanolin-based preparations should be avoided because of a possible allergy to wool.
DIF: Cognitive Level: Knowledge REF: Page 706
TOP: Infantile Eczema KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4. A 2-day-old infant is noted to have small pustules on her skin. What is the best nursing action?
a. Report it immediately because it may be a staphylococcus infection.
b. Keep the affected area dry and clean.
c. Teach the parents how to care for seborrheic dermatitis.
d. Chart the finding because it may be the beginning of a strawberry nevus.
ANS: A
A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must
be reported immediately.
DIF: Cognitive Level: Application REF: Page 708
TOP: Staphylococcal Infection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
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5. The home health nurse discovers a family infected with pediculosis. What information can the nurse provide
to the mother to start eradication of the lice?
a. Cover the hair with Vaseline.
b. Apply a soda-vinegar solution to the hair.
c. Comb through the hair with a vinegar-water solution.
d. Shampoo the hair with dish detergent.
ANS: C
Combing a vinegar and water solution through the hair with a fine-tooth comb and then shampooing is an
initial step toward eradication.
DIF: Cognitive Level: Application REF: Page 710
TOP: Tinea Capitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
6. A group of football players is taking oral griseofulvin for tinea pedis. What should the school nurse caution
them to avoid?
a. Citrus fruit and juice
b. Eating shellfish
c. Alcohol consumption
d. Taking corticosteroids
ANS: C
Consumption of alcohol while taking griseofulvin will cause severe tachycardia.
DIF: Cognitive Level: Comprehension REF: Page 709
TOP: Tinea Pedis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. What should the nurse suggest before a 17-N
yeUaR
r-SoIlN
dG
giTrB
l s.C
taOrtM
s a protocol of isotretinoin (Accutane) for her
acne?
a. Get a prescription for oral contraceptives.
b. Increase the dose of the present medication.
c. Limit intake of chocolate, cola, and peanuts.
d. Increase exposure to sunlight.
ANS: A
Oral contraceptives are often prescribed for adolescents with acne. Accutane can cause birth defects, so
pregnancy should be prevented.
DIF: Cognitive Level: Application REF: Page 704
TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
8. A child had a burn, evidenced by pink skin and blistering. The child complains of pain and is crying. How
does the nurse classify this burn when documenting?
a. First-degree
b. Second-degree superficial
c. Second-degree deep dermal
d. Third-degree
ANS: B
A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn
indicates tissue viability.
DIF: Cognitive Level: Analysis REF: Page 712
OBJ: 9 TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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9. A child has sustained a second-degree deep thermal burn to the hand. What is the best first action to take?
a. Immerse the burned area in cold water.
b. Apply ice to the burned area.
c. Break any blisters that are present.
d. Apply petroleum jelly to the burned skin.
ANS: A
First-aid treatment of a second-degree deep thermal burn is immersion of the burned area in water to halt the
burning process.
DIF: Cognitive Level: Application REF: Page 712
OBJ: 9 TOP: Burns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
10. Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns?
a. Penicillin
b. Iodine
c. Tetanus immunizations
d. Sulfa
ANS: D
The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy.
DIF: Cognitive Level: Knowledge REF: Page 712
OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
11. What would help the child with a serious burn meet nutritional needs during the subacute phase of
recovery?
a. Decrease calories because the child will be N
onUbReSdINreGsT
tB
an.C
dOwM
ill not need as many.
b. Increase calories and protein to compensate for the healing process.
c. Increase fat to replace the layer of fat next to the burned skin.
d. Decrease carbohydrates and starches because the pancreas is strained by the healing process.
ANS: B
Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased metabolic needs
of the child with burns.
DIF: Cognitive Level: Comprehension REF: Page 714
OBJ: 13 TOP: Burns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12. Which statement made by a parent indicates an understanding of the topical application of medications for
a skin condition?
a. I apply the medication after I give my child a bath.
b. I rub the ointment in a circular motion over the rash.
c. I increased the amount of cream because the rash was not improving.
d. I use powder and cornstarch to keep the skin dry.
ANS: A
Absorption of topical medications is best when preparations are applied after a warm bath.
DIF: Cognitive Level: Comprehension REF: Page 706
TOP: Topical Medications KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13. On the first day following a severe burn, the bodys fluid reserves have left the circulating volume and
entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the
burn victim?
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a. Increasing intracranial pressure
b. Reduced urine output
c. Eschar formation
d. Fluid overload
ANS: B
With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an
indication of altered renal function.
DIF: Cognitive Level: Application REF: Page 716
TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14. At a 2-month well-child visit, parents ask the nurse about the red area on the infants neck. They tell the
nurse that the mark appeared a few weeks after birth. What does the nurse recognize this skin lesion as?
a. A port wine nevus
b. A strawberry nevus
c. Exanthem
d. Intertrigo
ANS: B
The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which
may not become apparent for a few weeks after birth.
DIF: Cognitive Level: Comprehension REF: Page 701
OBJ: 3 TOP: Congenital Lesions
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. A mother is concerned about what might hNaU
veRcSaIN
usGeT
d Ba.C
heOaM
t rash on her infant. The nurse observes tiny
pinhead-sized reddened papules on the infants neck and axilla. What does the nurse explain as the most likely
cause of this rash?
a. Sun exposure
b. Allergic reaction
c. Infection
d. Heat and moisture
ANS: D
Miliaria, or prickly heat rash, is caused by excess body heat and moisture.
DIF: Cognitive Level: Comprehension REF: Page 702
TOP: Skin Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. What is the correct nursing response to a mother who asks, How can I get rid of the babys cradle cap?
a. Rub baby oil on the infants head at night and shampoo the hair the next morning.
b. Use a brush with firm bristles to loosen the scales on the babys head several times a day.
c. Wash the babys head every night with a dandruff-control shampoo.
d. Lubricate the babys head every morning with a small amount of olive oil.
ANS: A
Scales may be softened by applying baby oil to the head the evening before, and shampooing the hair in the
morning.
DIF: Cognitive Level: Application REF: Page 703
TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. Which statement made by a parent indicates the need for further teaching about strategies to control itching
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for the infant with eczema?
a. Wool is the best fabric for the infants clothing.
b. I should avoid laundry detergents with fragrances.
c. I put cotton gloves on the infants hands.
d. The infants fingernails are kept short.
ANS: A
Clothing should be made of cotton. Wool is avoided because of its allergy potential.
DIF: Cognitive Level: Comprehension REF: Page 706
TOP: Infantile Eczema KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. What will the nurse include when teaching about general skin care measures that could help prevent acne?
a. Eliminating chocolate, peanuts, and cola from the diet
b. Washing the face with a cleansing product frequently
c. Planning indoor activities to avoid sun exposure
d. Eating a balanced diet and getting sufficient rest
ANS: D
General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent
exacerbations.
DIF: Cognitive Level: Comprehension REF: Page 704
TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. What is
the most appropriate nursing action?
a. Report this sign immediately.
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b. Place a warm towel over the extremities.
c. Gently sponge with cool water.
d. Medicate for pain.
ANS: D
A purple flush indicates the return of sensation and causes extreme pain.
DIF: Cognitive Level: Application REF: Page 717
TOP: Frostbite KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. A child is brought to the emergency department with burns on the face and chest. What is the nurses first
priority?
a. Assess respiratory status.
b. Administer pain medication.
c. Remove clothing.
d. Insert a Foley catheter.
ANS: A
Airway assessment and establishing an airway are the initial priorities.
DIF: Cognitive Level: Application REF: Page 713
TOP: Burns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
21. An adolescent girl with acne is being treated with an antibiotic in addition to topical applications. What
side effect does the nurse caution the girl to expect?
a. Lessened effectiveness of oral contraceptives
b. Urinary burning and frequency
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c. Breast engorgement
d. Vaginitis
ANS: D
Antibiotic therapy can cause a monilial vaginitis.
DIF: Cognitive Level: Comprehension REF: Page 704
TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22. The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks.
Which complication does the nurse document and report?
a. Diverticulitis
b. Stress diarrhea
c. Curlings ulcer
d. Perforated bowel
ANS: C
Curlings ulcer is a complication of burn victims resulting from the stress of their trauma.
DIF: Cognitive Level: Application REF: Page 714
TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
23. A child is brought to the emergency department with severe frostbite. Which body parts should be warmed
first?
a. Hands and arms
b. Feet and legs
c. Fingers and toes
d. Head and torso
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ANS: D
In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the
extremities.
DIF: Cognitive Level: Application REF: Page 717
TOP: Frostbite KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. An adolescent is at the pediatricians office because he has been experiencing intense itching, particularly in
the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well.
With what is this symptom associated?
a. Scabies
b. Pediculosis capitis
c. Tinea corporis
d. Eczema
ANS: A
Intense itching, especially at night, is characteristic of scabies.
DIF: Cognitive Level: Comprehension REF: Page 710
TOP: Scabies KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25. What should the nurse stress to the mother of a child with impetigo?
a. The condition is caused by the herpes simplex virus type I.
b. The crusts on the lesions should be left in place.
c. The lesions may spread, but the disease is not contagious.
d. Small cuts and bites should be treated promptly.
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ANS: D
Small cuts and bites should be treated promptly to prevent the invasions of the bacteria that cause impetigo.
The crusts from the lesions should be gently removed. The disease is contagious.
DIF: Cognitive Level: Comprehension REF: Page 708
TOP: Impetigo KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
26. The nurse is caring for a 3-year-old with severe burns. What is the nurse aware is the minimum adequate
hourly urine output?
a. 5 mL/hr
b. 10 mL/hr
c. 15 mL/hr
d. 20 mL/hr
ANS: D
The minimum acceptable hourly urine output for children over the age of 2 years is 20 to 30 mL/hr.
DIF: Cognitive Level: Comprehension REF: Page 714
TOP: Urine Output after Burn KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis does the nurse
suspect?
a. Tuberous sclerosis
b. Eczema
c. Psoriasis
d. Systemic lupus erythematosus
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ANS: D
Butterfly rash over the nose and cheeks can be associated with photosensitivity and may be associated with
systemic lupus erythematosus (SLE).
DIF: Cognitive Level: Comprehension REF: Page 702
TOP: Skin Manifestations of Illness KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28. The nurse is documenting a description of a skin assessment. What term can be used for an elevated, fluidfilled blister?
a. Pustule
b. Papule
c. Wheal
d. Vesicle
ANS: D
A vesicle is an elevated, fluid-filled blister (cold sore, chickenpox).
DIF: Cognitive Level: Comprehension REF: Page 701
OBJ: 1 TOP: Skin Conditions
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. What should the nurse keep in mind when providing care to the school-age child hospitalized with a burn
injury?
a. Hospitalization will be brief.
b. Analgesics should be given immediately after dressing changes.
c. Contact with peers should be maintained.
d. Parents usually handle injury worse than the child.
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ANS: C
A burn injury is taxing to the child and parents. It requires long periods of hospitalization and frequent
readmissions. The accident itself is terrifying for the child but is made even worse if caused by disobedience.
Nurses encourage children to express their feelings. Analgesics are administered before painful procedures.
The long-term patient requires diversions of various types. School tutors are requested, and contact is
maintained with peers through cards or e-mail.
DIF: Cognitive Level: Comprehension REF: Page 716
TOP: Burns KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
30. Parents of a child show the nurse that their child has a flat strawberry nevus. What information can the
nurse provide in educating the parents regarding strawberry nevus? (Select all that apply.)
a. It is a rare skin variation.
b. It is harmless.
c. It gradually becomes raised.
d. Laser treatment is available.
e. Sometimes it can disappear spontaneously.
ANS: B, C, D
The strawberry nevus is a common hemangioma (consists of dilated capillaries in the dermal space) that may
not become apparent for a few weeks after birth. Although it is harmless and usually disappears without
treatment, it is disturbing to parents, especially when it appears on the head or face. At first it is flat, but it
gradually becomes raised. The lesions gradually blanch, with 60% disappearing spontaneously by 5 years of
age and 90% disappearing by 9 years of age. Laser treatment or excision may be considered if the area
becomes ulcerated.
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DIF: Cognitive Level: Knowledge REF: Page 700
OBJ: 3 TOP: Strawberry Nevus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31. What would the nurse teach parents to do in order to avoid diaper rash? (Select all that apply.)
a. Use ointments.
b. Keep perineum covered at all times.
c. Use disposable diapers.
d. Avoid plastic bloomers or pants.
e. Change diaper frequently.
ANS: A, C, D, E
Keeping the skin dry and protected with emollients, leaving the area exposed to light and air periodically,
changing the diaper frequently, and avoiding plastic pants will prevent diaper rash.
DIF: Cognitive Level: Comprehension REF: Page 703
TOP: Avoiding Diaper Rash KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32. The nurse speaking to a group of junior high school students informs them that acne can be exacerbated by
which drug(s)? (Select all that apply.)
a. Steroids
b. Phenytoin
c. Phenobarbital
d. Aspirin
e. Oral contraceptives
ANS: A, B, C
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Long-term use of steroids, phenytoin, phenobarbital, lithium, and vitamin B12 can cause acne.
DIF: Cognitive Level: Knowledge REF: Page 704
TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33. What intervention(s) would the nurse preparing a teaching plan for the care of a child with infantile eczema
include? (Select all that apply.)
a. Bathe the child using products with a light fragrance.
b. Use oatmeal and baking soda as bath additives.
c. Add bath oil to bath water after the child has soaked.
d. Apply lanolin-based lotions after the bath.
e. Bathe child several times a day.
ANS: B, C
Use of oatmeal, baking soda, and baking powder is soothing. Adding oil to the bath water after the child has
soaked for a while makes the oil application more effective. Items with any fragrance should be avoided as
well as lanolin-based products. Many dermatologists advise minimal bathing.
DIF: Cognitive Level: Comprehension REF: Page 706
TOP: Infantile Eczema KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34. Which factor(s) activate the herpes simplex virus type I? (Select all that apply.)
a. Stress
b. Sun
c. Menses
d. Fever
e. Food allergies
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ANS: A, B, C, D
The herpes simplex virus type I can be activated to cause a cold sore by exposure to stress, sun, initiation of
menses, and fever. Food allergies do not activate the virus as a rule.
DIF: Cognitive Level: Comprehension REF: Page 705
TOP: Herpes Simplex Type I KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
35. The nurse recognizes the blisters and erythema of the hands of a person recovering from frostbite as the
skin disorder called
.
ANS:
chilblain
After exposure to cold, blisters appear on the hands and feet that are similar to a burn. These are called
chilblains.
DIF: Cognitive Level: Knowledge REF: Page 717
TOP: Chilblain KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
36. The nurse differentiates a type of topical medication that is an oil-based emulsion to be used on dry skin as
a(n)
.
ANS:
ointment
Ointments are oil-based emulsions that are used on dry skin.
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DIF: Cognitive Level: Comprehension REF: Page 708
OBJ: 6 TOP: Ointment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
37. A 5-year-old boy is brought to the emergency department with a second-degree burn of his entire right arm
and hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the body surface area
(BSA) percentage burn as
%.
ANS:
26
Using the Burn Size Estimation Table on page 695, the nurse can determine that for a 5-year-old child, the
upper and lower arm = 5.5%, the hand = 2.5%, anterior trunk = 13%, genital area = 1%, and half of the thigh =
4%. Together this totals to 26% BSA burn.
DIF: Cognitive Level: Analysis REF: Page 711
OBJ: 9 TOP: BSA Burn Estimation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
38. The nurse recognizes the characteristic circular hairless patches of tinea capitis, which is called
.
ANS:
alopecia
Alopecia is the term to refer to hair loss.
DIF: Cognitive Level: Knowledge REF: Page 709
TOP: Alopecia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: PhysiN
olUoR
giScIaNl G
ATdB
ap.CtaOtiM
on
39. The nurse assesses a major burn as a
-thickness burn involving
% or more of the body surface.
ANS:
full; 10
A full-thickness burn involving 10% or more of the body surface is considered a major burn.
DIF: Cognitive Level: Knowledge REF: Page 711
OBJ: 9 TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
40. Eczema indicates that the infant is oversensitive to certain substances called
the body via the digestive tract, inhalation, direct contact, or injections.
, which enter
ANS:
allergens
Eczema is actually a symptom rather than a disorder. It indicates that the infant is oversensitive to certain
substances called allergens, which enter the body via the digestive tract (food), by inhalation (dust, pollen), by
direct contact (wool, soap, strong sunlight), or by injections (insect bites, vaccines).
DIF: Cognitive Level: Knowledge REF: Page 705
TOP: Eczema KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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Chapter 31: The Child with a Metabolic Condition
MULTIPLE CHOICE
1. A nurse is planning to teach a family about Tay-Sachs disease. What will the nurse relay about the pattern of
inheritance for inborn errors of metabolism?
a. They are usually autosomal recessive.
b. They are usually autosomal dominant.
c. They are usually X-linked recessive.
d. They are usually multifactorial.
ANS: A
The pattern of inheritance is generally autosomal recessive.
DIF: Cognitive Level: Knowledge REF: Page 720
TOP: Tay-Sachs KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. What occurs as a result of an inadequate secretion of insulin?
a. Protein synthesis is increased.
b. Increased fat breakdown leads to ketonemia.
c. Serum glucose levels are markedly decreased.
d. More rapid conversion and storage of carbohydrates to glucose occurs.
ANS: B
When insulin is deficient, the body cannot metabolize carbohydrates for energy. The body is also unable to
store and use fat properly. Incomplete fat metabolism produces ketone bodies that accumulate in the blood.
DIF: Cognitive Level: Comprehension REF: Page 722
CO
TOP: Diabetes Mellitus KEY: Nursing ProcesN
sU
SR
teSpI:NIG
mTpB
le.m
enMtation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. On what understanding does the nurse plan the care of a child with a new diagnosis of type 1 diabetes
mellitus?
a. There is an absolute deficiency of insulin.
b. Insufficient quantities of insulin are produced by the pancreas.
c. Oral hypoglycemic agents can control it.
d. Insulin deficiency is caused by another disease affecting the pancreas.
ANS: A
Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete deficiency of insulin.
DIF: Cognitive Level: Comprehension REF: Page 723
OBJ: 5 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. A child receives a combination of regular and NPH insulin at 8:00 AM. At 8:45 AM the breakfast trays have
not yet arrived from the kitchen. What is the best action by the nurse?
a. Notify the charge nurse.
b. Give the patient a snack of graham crackers and milk.
c. Ambulate the patient in the hall for a short time.
d. Give the patient more insulin according to the sliding scale.
ANS: B
A child who receives regular insulin before meals may have an insulin reaction if food is not eaten within 20
minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia.
DIF: Cognitive Level: Application REF: Page 730
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OBJ: 9 TOP: Prevention of Hypoglycemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
5. Although the child with type 1 diabetes had her prescribed insulin at 7:30 AM, the child is complaining of
hunger and thirst and is drowsy at 10:30 AM. What should the nurse do first?
a. Walk the patient in the hall for 10 minutes.
b. Allow the patient a short nap.
c. Give her a cup of orange juice.
d. Test her blood with a glucometer and give insulin according to the sliding scale.
ANS: C
The immediate remedy is to give orange juice to raise the blood glucose. Giving more sugar will increase the
blood glucose in a hyperglycemic child. Walking exercise will use up even more glucose. The treatment for
hyperglycemia is to give the patient more insulin.
DIF: Cognitive Level: Application REF: Page 730
OBJ: 7 TOP: Hypoglycemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
6. Which comment made by a school-age child indicates that he needs more teaching about diabetes mellitus
and exercise?
a. I carry a piece of hard candy with me in case I start to feel shaky.
b. I make sure I have emergency money when I have soccer practice or a game.
c. Sometimes I skip my breakfast when I have a game in the morning.
d. I play in soccer games that are scheduled after dinner.
ANS: C
Blood glucose is high after meals. The child wNitUhRtySpIN
eG
1TdBia.C
beOtM
es mellitus who skips a meal before exercise is
at risk for hypoglycemia.
DIF: Cognitive Level: Comprehension REF: Page 727
OBJ: 9 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. Which statement made by a 7-year-old child with type 1 diabetes mellitus indicates a need for more
teaching?
a. My pancreas is sick and needs insulin until it is well.
b. I will need to take my insulin every day.
c. I need to keep a piece of candy in my pocket in case I start to feel shaky.
d. My mom has to give me insulin shots twice a day.
ANS: A
The child with type 1 diabetes mellitus has an insulin deficiency and will require lifelong management of this
disease. Insulin does not cure the pancreas.
DIF: Cognitive Level: Comprehension REF: Page 726
TOP: Diabetes Mellitus KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
8. Which general dietary measure should the nurse include in a teaching plan for the child with type 1 diabetes
mellitus?
a. Control intake of carbohydrates and consume fewer calories.
b. Focus on complex carbohydrates and eat foods high in fiber.
c. Obtain most calories from proteins and fats.
d. Eat a diet low in fat and low in complex carbohydrates.
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ANS: B
The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic
child, with the exception of the elimination of concentrated carbohydrates such as sugar. Fiber has been shown
to reduce blood glucose levels.
DIF: Cognitive Level: Comprehension REF: Page 728
TOP: Diet KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. A child with diabetes is brought to the emergency department. He is flushed and drowsy, and his skin is dry.
His father states that the child has been feeling progressively worse since the morning. What is this child most
likely experiencing?
a. Somogyi phenomenon
b. Dawn syndrome
c. Ketoacidosis
d. Water intoxication
ANS: C
In ketoacidosis, the childs skin is dry, and the face is flushed. Patients appear dehydrated. They may perspire
and be restless. The breath has a fruity odor, and there is no rest period between inspiration and expiration.
DIF: Cognitive Level: Analysis REF: Page 725
OBJ: 7 TOP: Ketoacidosis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. A mother reports that her 4-month-old infant is lethargic, sleeps 18 hours a day, and snores. The nurse
recognizes these signs are characteristic of what?
a. Hypothyroidism
b. Hyperthyroidism
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c. Type 1 diabetes mellitus
d. Tay-Sachs disease
ANS: A
The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy
respiration.
DIF: Cognitive Level: Analysis REF: Page 721
TOP: Hypothyroidism KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. What is an important consideration for the school-age child taking DDAVP for diabetes insipidus?
a. Observe for signs of water deprivation.
b. Restrict his physical education program.
c. Arrange for the child to use the bathroom when needed.
d. Limit fluid intake other than during the lunch period.
ANS: C
The child with diabetes insipidus needs liberal access to bathrooms and water fountains. Arrangements may
have to be made with the school to allow access.
DIF: Cognitive Level: Application REF: Page 721
OBJ: 4 TOP: Diabetes Insipidus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. Which laboratory result indicates good metabolic control for a child with type 1 diabetes mellitus?
a. Glycosylated hemoglobin value of 8%
b. Fasting blood glucose level less than 140 mg/dL
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c. Glucose tolerance test result of 190 mg/dL
d. No glucose or ketones present in the urine
ANS: A
Glycosylated hemoglobin reflects glycemic levels over a period of months. Levels of 6% to 9% represent good
metabolic control.
DIF: Cognitive Level: Comprehension REF: Page 725
TOP: Hemoglobin A1c KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. What condition does the nurse suspect when a child with type 1 diabetes mellitus has hyperglycemia,
diaphoresis, and headaches in the morning?
a. Dawn phenomenon
b. Somogyi phenomenon
c. Honeymoon effect
d. Ketoacidosis
ANS: B
The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the
point at which the bodys counter-regulatory hormones are released, producing the symptoms described.
DIF: Cognitive Level: Analysis REF: Page 732
TOP: Somogyi Phenomenon KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
14. What would be the most appropriate nursing response to a woman who says, My sister had a child with
Tay-Sachs disease, and I want to know if I could have a child with this condition?
a. The disease is rare. It is unlikely that you would have a child with Tay-Sachs disease.
b. A screening test can be done to determine ifNyUoRuSaIrNeGaTcBa.rCriO
erMof the gene.
c. The gene for Tay-Sachs disease is transmitted by the father.
d. The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus.
ANS: B
Carriers can be identified by screening tests. Tay-Sachs disease has an autosomal recessive pattern of
transmission.
DIF: Cognitive Level: Comprehension REF: Page 720
OBJ: 2 TOP: Tay-Sachs Disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. What statement by a parent leads the nurse to determine a parent is administering levothyroxine
(Synthroid) correctly?
a. I stopped giving the medication because my daughter was losing her hair.
b. I am using a different brand now because it costs less money.
c. I dont give the medication on the weekends.
d. I give the medication at 8:00 AM every day.
ANS: D
Synthroid should be given at the same time each day, preferably in the morning.
DIF: Cognitive Level: Comprehension REF: Page 721
TOP: Levothyroxine (Synthroid) KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
16. After a closed head injury, the unconscious 10-year-old child begins to excrete copious amounts of pale
urine with an attendant drop in blood pressure (BP). Based on these symptoms, what does the nurse suspect has
developed?
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a. Diabetes insipidus
b. Diabetes mellitus
c. Hypothyroidism
d. Hyperthyroidism
ANS: A
Diabetes insipidus can be acquired as the result of a head injury or tumor, and suppression of the posterior
pituitary causes copious urine output with an attendant drop in BP. The child can become dehydrated very
quickly if some remedy is not applied.
DIF: Cognitive Level: Analysis REF: Page 721
OBJ: 2 TOP: Diabetes Insipidus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. The nurse is teaching the parents of a child with diabetes insipidus about water intoxication. The nurse
would tell the parents to be alert for what symptom? For
a. Polyuria
b. Cough
c. Weight loss
d. Lethargy
ANS: D
Signs of water intoxication include edema, lethargy, nausea, and central nervous system signs.
DIF: Cognitive Level: Comprehension REF: Page 721
OBJ: 2 TOP: Diabetes Insipidus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
NURSINGTB.COM
18. The parents of a child newly diagnosed with diabetes mellitus tell the nurse, Our sons body is resistant to
insulin. With what does the nurse recognize this description is consistent?
a. Type 1, insulin-dependent diabetes mellitus
b. Type 2, noninsulin-dependent diabetes mellitus
c. Maturity-onset diabetes of youth
d. Drug-induced diabetes
ANS: B
Type 2, noninsulin-dependent diabetes mellitus is caused by insulin resistance or failure of the body to use the
insulin.
DIF: Cognitive Level: Comprehension REF: Page 723
TOP: Insulin Resistance KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. What does the nurse instruct a 12-year-old to do when teaching how to administer insulin?
a. Make sure injection sites are 6 inches apart.
b. Select an injection site that was recently exercised.
c. Inject the needle at a 90-degree angle.
d. Give the injection deep into the muscle.
ANS: C
Children often find it easier to learn to inject the needle at a 90-degree angle.
DIF: Cognitive Level: Application REF: Page 729
TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
20. The nurse discussed treatment of hypoglycemia with an adolescent. Which statement by the adolescent
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leads the nurse to determine the patient understood the instructions?
a. When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers.
b. When my blood glucose is low or if I begin to feel hungry and weak, I will give myself Lispro insulin.
c. When my blood glucose is low or if I begin to feel hungry and weak, I will have a slice of cheese.
d. When my blood glucose is low or if I begin to feel hungry and weak, I will drink a diet soda.
ANS: A
The immediate treatment of hypoglycemia consists of administering sugar in some form such as orange juice,
hard candy, or a commercial product. Cheese will eventually raise the blood glucose, but not as quickly as
candy.
DIF: Cognitive Level: Application REF: Page 732
TOP: Diabetes Mellitus KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
21. Why does the nurse instruct an 11-year-old diabetic child to use the side of the finger for blood testing?
a. It has fewer capillaries.
b. It is easier to puncture.
c. It is less likely to become infected.
d. It has fewer nerve endings.
ANS: D
The sides of the finger have fewer nerve endings and more capillaries but are not easier to puncture than the
fingertip. The risk for infection is remote for either site.
DIF: Cognitive Level: Comprehension REF: Page 726
TOP: Finger Stick KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22. What is the function of an insulin pump? NURSINGTB.COM
a. Releases insulin as blood glucose rises
b. Provides continuous infusion of insulin
c. Decreases need for painful glucose monitoring
d. Delivers a prescribed amount of insulin twice a day
ANS: B
The insulin pump that is attached to a subcutaneous tube releases a continuous infusion of insulin.
DIF: Cognitive Level: Knowledge REF: Page 730
TOP: Insulin Pump KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23. The nurse is preparing to administer a long-acting insulin. Which insulin is considered long acting?
a. Lispro
b. Aspart
c. Glargine
d. Regular
ANS: C
Insulin glargine is a long-acting insulin. Regular is short acting. Lispro and Aspart are rapid acting.
DIF: Cognitive Level: Knowledge REF: Page 730
OBJ: 10 TOP: Insulin KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
24. When discussing possible causes of diabetes in children, the nurse mentions chromosomal defects. Which
chromosomes are associated with diabetes? (Select all that apply.)
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a. 6
b. 7
c. 12
d. 20
e. 21
ANS: A, B, C, D
Defects in chromosomes 6, 7, 12, and 20 and other genetic disorders are associated with diabetes mellitus
syndrome.
DIF: Cognitive Level: Knowledge REF: Page 723
TOP: Diabetes Mellitus KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. Which food sources are high in soluble fiber? (Select all that apply.)
a. Raw fruits
b. Cooked vegetables
c. Beans
d. Lean meat
e. Bran cereal
ANS: A, C, E
Foods high in soluble fiber include raw fruits, beans, and bran cereal.
DIF: Cognitive Level: Comprehension REF: Page 728
TOP: Dietary Fiber Sources KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26. What does the nurse remind the adolescent with diabetes that soluble fiber in the diet can reduce? (Select
all that apply.)
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a. Blood glucose
b. Serum cholesterol
c. Incidence of infections
d. Absorption of sugar
e. Insulin requirements
ANS: A, B, D, E
Soluble fiber can reduce blood glucose, serum cholesterol, absorption of sugar, and insulin requirements. It has
no effect on infections.
DIF: Cognitive Level: Comprehension REF: Page 728
TOP: Fiber in Diet KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27. Which process(es) does the nurse explain the endocrine system is primarily responsible for controlling?
(Select all that apply.)
a. Maturation
b. Reproduction
c. Stress response
d. Sexual identity
e. Growth
ANS: A, B, C, E
The endocrine system governs maturation, reproduction, stress response, and sexual maturity. Sexual identity
is a psychosocial response.
DIF: Cognitive Level: Comprehension REF: Page 719
TOP: Endocrine System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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28. The home health nurse is monitoring an 8-month-old child with hypothyroidism taking levothyroxine
(Synthroid). Which symptoms does the nurse recognize as signs of overdose? (Select all that apply.)
a. Tachycardia
b. Irritability
c. Vomiting
d. Weight gain
e. Diaphoresis
ANS: A, B, E
All the options with the exception of weight gain and vomiting are indications of overdose of Synthroid.
Weight loss is a symptom of overdose, however.
DIF: Cognitive Level: Comprehension REF: Page 722
TOP: Levothyroxine (Synthroid) Overdose
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
29. What makes keeping diabetes in control in an adolescent difficult? (Select all that apply.)
a. Hormonal changes
b. Developmental conflicts
c. Preference for fast food
d. Growth spurts
e. Knowledge of disease
ANS: A, B, C, D
The adolescent who is in a growth spurt and filled with raging hormones resents and denies the need to be
dependent on a medication. Medication schedules and diet restrictions do not correlate well with the
adolescents lifestyle of eating fast foods. Denial of disease is prevalent in the adolescent.
DIF: Cognitive Level: Comprehension REF: PNaU
geRS7I3N3GTB.COM
OBJ: 8 TOP: Diabetic Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30. A child with diabetes mellitus is observed to have cold symptoms. What signs and symptoms will alert
parents of the possibility of ketoacidosis? (Select all that apply.)
a. Chest congestion
b. Ear pain
c. Fruity breath
d. Hyperactivity
e. Nausea
ANS: C, E
Symptoms of ketoacidosis are compared with those of hypoglycemia. Signs and symptoms include a fruity
odor to the breath, nausea, decreased level of consciousness and dehydration. Lab values include ketonuria,
decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration.
DIF: Cognitive Level: Comprehension REF: Page 725
TOP: Ketoacidosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
31. The nurse is discussing insulin shock with parents of a child recently diagnosed with diabetes mellitus.
What will the nurse respond when the parents ask why children are more prone to insulin reactions? (Select all
that apply.)
a. The condition is more unstable in children.
b. Parents are often noncompliant.
c. The activities are irregular.
d. They are still growing.
e. Sleep patterns are not established.
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ANS: A, C, D
Children are more prone to insulin reactions than adults because of the following: the condition itself is more
unstable in young people; they are growing; their activities are more irregular.
DIF: Cognitive Level: Comprehension REF: Page 732
TOP: Insulin Shock KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
COMPLETION
32. The nurse reminds the parents of a diabetic with an insulin pump that the tubing of the pump should be
changed aseptically every
hours.
ANS:
48
The tubing of the insulin pump should be changed every 48 hours.
DIF: Cognitive Level: Knowledge REF: Page 730
TOP: Insulin Pump KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
33. The nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level is
mg/dL on two separate occasions, and the history is positive for indication of the disease.
ANS:
126
An elevated blood glucose level of 126 mg/dL on two separate occasions is grounds for the diagnosis of
diabetes mellitus when the history is positive fNoU
rR
thSeIN
diG
seTaBse.C. OM
DIF: Cognitive Level: Comprehension REF: Page 723
TOP: Diagnosis of DM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
34. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can evaluate average
glucose levels over a period of
to
months.
ANS:
3; 4
Glucose attaches to the red cells over the life span of the cell and can be read as percentages. An HbA1c
reading of 6% to 9% is normal; a reading of 12% or higher is indicative of DM.
DIF: Cognitive Level: Knowledge REF: Page 725
TOP: Glycosylated Hemoglobin KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
35. Long-acting types of insulin are seldom given to children because of the danger of
during sleep.
ANS:
hypoglycemia
Long-acting types of insulin are seldom given to children because of the danger of hypoglycemia during sleep.
DIF: Cognitive Level: Comprehension REF: Page 731
TOP: Insulin administration/Hypoglycemia
KEY: Nursing Process Step: Implementation
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INTRODUCTION TO MATERNITY AND PEDIATRIC NURSING 8TH EDITION LEIFER TEST BANK
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural
Disasters and the Maternal-Child Patient
MULTIPLE CHOICE
1. Which classification of medication would make a child most susceptible to an opportunistic infection?
a. Anticonvulsant
b. Beta-adrenergic agent
c. Antibiotic
d. Corticosteroid
ANS: D
Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections.
DIF: Cognitive Level: Knowledge REF: Page 741
TOP: Effect of Steroids KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. An 8-year-old asks the nurse how she got the antibodies that kept her from getting whooping cough. What is
the nurses best explanation?
a. You received borrowed antibodies from another person who had whooping cough.
b. You were given a tiny case of whooping cough and then you made your own antibodies.
c. An immunization strengthened antibodies you were born with.
d. You received only temporary borrowed antibodies and you need to have another shot every 5 years.
ANS: B
Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the
body to develop an immune reaction and antibodies. This is active acquired immunity.
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Page 744 REF:
DIF: Cognitive Level: Comprehension
OBJ: 4 TOP: Vaccines KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. How would the nurse document a rash that has erythematous, circular raised lesions?
a. Macular
b. Papular
c. Vesicular
d. Pustular
ANS: B
A papule is a circular, reddened elevated area on the skin.
DIF: Cognitive Level: Knowledge REF: Page 743
TOP: Rashes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which finding would lead the nurse to delay the administration of DTaP for an infant?
a. Diarrhea
b. Temperature of 40.5 C (105 F) from the previous inoculation
c. Teething
d. Traveling to Europe in a week
ANS: B
A contraindication to giving the DTaP vaccine is a 40.5 C (105 F) temperature following the previous
vaccination.
DIF: Cognitive Level: Application REF: Page 747
TOP: Immunizations KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. What type of precautions are necessary when caring for a toddler with varicella?
a. Contact
b. Protective
c. Airborne infection
d. Large droplet infection
ANS: C
Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubella.
Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room.
DIF: Cognitive Level: Application REF: Page 738
OBJ: 4 TOP: Medical Asepsis and Standard Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
6. Which statement assures the nurse that parents understand how long a child who has varicella is contagious?
a. My child should stay home from school for 6 days after the pox appear.
b. My child can return to school when the rash fades.
c. My child must stay away from other children until all of the lesions have healed.
d. My child is contagious as long as he has a fever.
ANS: A
The child with varicella is contagious for 6 days after the appearance of the rash.
DIF: Cognitive Level: Comprehension REF: Page 738
OBJ: 2 TOP: Common Varicella
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environm
t:SSIN
afG
etTyBa.C
ndOIM
nfection Control
NeUnR
7. Which statement made by a sexually active adolescent girl indicates an understanding of the prevention of
sexually transmitted diseases?
a. I always douche after intercourse.
b. I think you can get a vaccination for STDs now.
c. I insist that my partner wear a condom.
d. I am protected because I take the pill.
ANS: C
The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual
intercourse.
DIF: Cognitive Level: Comprehension REF: Page 755
OBJ: 9 TOP: Sexually Transmitted Diseases
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
8. What is the priority nursing diagnosis for a hospitalized infant who is HIV positive?
a. Risk for injury
b. Altered nutrition
c. Impaired skin integrity
d. Risk for infection
ANS: D
The infant who is HIV positive has impaired immunologic functioning and is at high risk for infection.
DIF: Cognitive Level: Application REF: Page 758
OBJ: 10 TOP: Human Immunodeficiency Virus
KEY: Nursing Process Step: Nursing Diagnosis
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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
9. The mother of a newborn asked the nurse, When will my baby get the hepatitis B vaccine? When will the
nurse explain the first dose of Comvax should be given to infants born to a hepatitis B-positive mother?
a. Within 12 hours after birth
b. Within 2 weeks after birth
c. Within 1 month after birth
d. Within 2 months after birth
ANS: A
The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine,
should be used for infants born to HBsAg-positive mothers within 12 hours of birth.
DIF: Cognitive Level: Knowledge REF: Page 749
OBJ: 4 TOP: Immunization Schedule
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10. A 10-year-old child is diagnosed with Hepatitis A. What is the most likely way the child contracted this
disease?
a. Came in contact with infected blood
b. Came in contact with droplets in the air
c. Was bitten by a mosquito or a tick
d. Ate shrimp while in Mexico
ANS: D
Hepatitis A results from ingestion of contaminated water or shellfish.
DIF: Cognitive Level: Comprehension REF: Page 739
OBJ: 3 TOP: Hepatitis A KEY: Nursing ProceNsU
sR
StSeIpN:GIm
pl.C
em
TB
OeMntation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
11. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when
caring for the infant?
a. Large-droplet infection precautions
b. Airborne-infection precautions
c. Contact precautions
d. Protective precautions
ANS: C
Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch
of a contaminated fomite.
DIF: Cognitive Level: Application REF: Page 742
OBJ: 4 TOP: Medical Asepsis and Standard Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most
appropriate response for the nurse to make when the child asks, Why do you have to wear a gown and mask
when you are in my room?
a. Nurses and doctors wear gowns and masks because you have a condition that could be spread to others.
b. The gown and mask are to protect you because you could get an infection very easily.
c. Im wearing this because there are a lot of bacteria in the hospital.
d. I might look scary but you wont need this after you have had medication for 24 hours.
ANS: B
Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly
susceptible to infection.
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DIF: Cognitive Level: Application REF: Page 743
TOP: Protective Isolation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
13. The nurse is planning to administer immunizations at a well-child visit when a parent reports the 18-month
old child is allergic to eggs. Which vaccine would be contraindicated?
a. Influenza
b. Inactivated polio vaccine
c. Diphtheria, tetanus, acellular pertussis
d. Hepatitis B
ANS: A
The influenza vaccine should not be given to children who are allergic to eggs.
DIF: Cognitive Level: Knowledge REF: Page 745
TOP: Nurses Role in ImmunizationsAllergy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
14. The nurse is preparing to administer immunizations at a well-child clinic. Which method of administration
will the nurse implement?
a. DTaP subcutaneously
b. Hib vaccine prepared in a separate syringe
c. Varicella intramuscularly
d. Varicella 1 week after the MMR vaccine
ANS: B
Hib vaccine must be given in a separate syringe from other vaccines administered at the same time.
DIF: Cognitive Level: Knowledge REF: PageN7U
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OBJ: 6 TOP: Hib KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15. A child was sent to the school nurse because of a rash. The nurse noted the rash was present on the trunk,
extremities, and face. The childs cheeks were bright red. With what is the nurse aware this type of rash is
consistent?
a. Measles
b. Roseola
c. Varicella
d. Fifth disease
ANS: D
In fifth disease, the child has a generalized rash and the cheeks have a slapped-cheek appearance.
DIF: Cognitive Level: Comprehension REF: Page 738
OBJ: 2 TOP: Fifth Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
16. What statement leads the nurse to determine that a childs parent understands information related to tick
bites?
a. Ill have my son wear dark clothing on his hike.
b. We should all get the Lyme disease vaccine before our trip.
c. Ill get a prescription for amoxicillin to take with us.
d. We will wear long pants and long-sleeved shirts in the woods.
ANS: D
People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites.
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DIF: Cognitive Level: Application REF: Page 740
OBJ: 4 TOP: Prevention of Tick Bites
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
17. An adolescent is taking tetracycline for a sexually transmitted disease. What would the nurse stress when
providing instruction about this medication?
a. Finish all of the medication.
b. Get plenty of fresh air and sunlight.
c. Take the medication with food.
d. Take an antacid if the medication causes an upset stomach.
ANS: A
The nurse would teach the adolescent to take all of the prescribed medication to avoid making the
microorganism resistant to tetracyclines.
DIF: Cognitive Level: Comprehension REF: Page 756
OBJ: 9 TOP: Sexually Transmitted Diseases
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18. The nurse explains to the parents that their child is in the prodromal stage of varicella. What does this
mean?
a. The child is now immune to varicella.
b. The child has varicella but has not yet broken out.
c. The child is infected with varicella but is not contagious.
d. The child does not have varicella but has been exposed to it.
ANS: B
SIuNnG
The prodromal stage is the initial stage of the N
coUmRm
icTaB
bl.eCO
diM
sease in which the child is infected and
contagious but does not yet have outward signs of the disease.
DIF: Cognitive Level: Comprehension REF: Page 741
TOP: Prodromal Period KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
19. Which is an example of an opportunistic infection?
a. Measles
b. Pneumocystis jiroveci
c. Clostridium difficile
d. Smallpox
ANS: B
Pneumocystis jiroveci is the most common of opportunistic diseases.
DIF: Cognitive Level: Knowledge REF: Page 757
TOP: Opportunistic Diseases KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
20. A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh. Patient
history reveals the child had a 2-cm laceration on the right thigh prior to infection. When explaining the chain
of infection, how does the nurse identify this laceration?
a. Reservoir
b. Portal of entry
c. Portal of exit
d. Cector
ANS: B
The chain of infection refers to the way in which organisms spread and infect the individual. A portal of entry
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is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which
the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth o
organisms (e.g., standing, stagnant water). A vector is an insect or animal that carries and spreads a disease.
DIF: Cognitive Level: Comprehension REF: Page 741
TOP: Chain of Infection KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
21. Why would a female adolescent with STDs resist reporting the condition? (Select all that apply.)
a. She is reluctant to name contacts.
b. She is embarrassed.
c. She doubts confidentiality.
d. She doesnt want to take the medication.
e. She dreads the pelvic examination.
ANS: A, B, C, E
Adolescents are uncomfortable about the pelvic examination and require a lot of support. Adolescents doubt
the confidentiality of the agency and are reluctant to name contacts.
DIF: Cognitive Level: Comprehension REF: Page 755
OBJ: 9 TOP: Reporting STDs
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
22. What sources are examples of acquired immunity? (Select all that apply.)
a. Gamma globulin
b. The disease
c. Maternal antibodies
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d. The vaccine
e. Immune globulin
ANS: B, D
Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma
globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some
other source, giving the person an immediate immunity but one that does not last.
DIF: Cognitive Level: Knowledge REF: Page 742
TOP: Acquired Immunity KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
23. The well-child clinic nurse is preparing to give which immunizations to a healthy 2-month-old? (Select all
that apply.)
a. DTaP
b. Hib
c. IPV
d. MMR
e. PCV
ANS: A, B, C, E
All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps,
measles, rubella are not expected until the child is 1 year old.
DIF: Cognitive Level: Knowledge REF: Page 749
OBJ: 6 TOP: Inoculations for a 2-Month-Old
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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24. The nurse is explaining to a family about disaster preparedness. What will the nurse instruct the family to
prepare in a disaster kit in case of emergency? (Select all that apply.)
a. Small television
b. Vital documents
c. Nonperishable food
d. Pet food
e. Blankets
ANS: B, C, D, E
The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or manmade
disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) office
guidelines for preparing a family and community disaster plan state that the family should keep several days
supply of food, water, pet food, warm clothing, blankets, copies of vital documents, and toiletries on hand. A
battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential.
DIF: Cognitive Level: Knowledge REF: Page 754
OBJ: 8 TOP: Disaster Preparedness
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
25. The nurse is assisting with an admission assessment of a child with scarlet fever. Which actions will the
nurse expect to implement? (Select all that apply.)
a. Obtain a throat culture.
b. Encourage ambulation.
c. Assess for desquamation.
d. Initiate droplet precautions.
e. Administer isoniazid.
ANS: A, C
A diagnosis of scarlet fever would indicate thrNoU
atRcSuIlN
tuGreTB
an.CdOaM
ssessment for desquamation. Bed rest with quiet
activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered
for tuberculosis.
DIF: Cognitive Level: Application REF: Page 740
OBJ: 2 TOP: Scarlet Fever
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
26. The nurse explains that the
test determines the childs susceptibility to tuberculosis.
ANS:
Mantoux
The Mantoux test is a screening test for the susceptibility to TB. An intradermal injection is given and read 3
days later. An erythema and induration of more than 5 mm is considered a positive reading.
DIF: Cognitive Level: Knowledge REF: Page 742
TOP: Mantoux KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27. The nurse uses a diagram showing how the wood tick acts as a(n)
Lyme disease.
ANS:
vector
A vector is an insect or animal that carries a communicable disease.
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DIF: Cognitive Level: Comprehension REF: Page 741
TOP: Vector KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28. The school nurse recognizes the presence of macules, papules, vesicles, pustules, and scabs on the child as
the particular sign of the communicable disease of
.
ANS:
varicella (chickenpox)
Varicella has the distinctive sign of showing several types of skin lesions at the same time.
DIF: Cognitive Level: Comprehension REF: Page 738
OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
29. A parent is concerned because her son was exposed to varicella at preschool. The nurse would tell this
parent that the incubation period for varicella is
days.
ANS:
14 to 21
The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days.
DIF: Cognitive Level: Knowledge REF: Page 738
OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
30. The nurse demonstrates proper hand hygiene pointing out that the process should take a minimum of
seconds.
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ANS:
15
Hand hygiene should take a minimum of 15 seconds to complete.
DIF: Cognitive Level: Knowledge REF: Page 743
OBJ: 4 TOP: Hand Hygiene
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
31. Children are generally more vulnerable to biological warfare, because their
not fully developed.
are
ANS:
immune systems
The immune systems of children are not fully developed, which makes them a vulnerable population.
DIF: Cognitive Level: Comprehension REF: Page 753
TOP: Bioterrorism KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
32. A
is a worldwide high incidence of a communicable disease. An
is a sudden
increase of a communicable disease in a localized area.
refers to a continuous incidence
of a communicable disease expected in a localized area.
ANS:
pandemic; epidemic; Endemic
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A pandemic is a worldwide high incidence of a communicable disease. An epidemic is a sudden increase of a
communicable disease in a localized area. Endemic refers to a continuous incidence of a communicable disease
expected in a localized area.
DIF: Cognitive Level: Knowledge REF: Page 741
TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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Chapter 33: The Child with an Emotional or Behavioral Condition
MULTIPLE CHOICE
1. A parent asks the nurse to describe what is meant by a learning disability. Which is the nurses most helpful
response?
a. A child may have difficulty with perception, language, comprehension, or memory.
b. It is characterized by inattention, impulsiveness, and hyperactivity.
c. The childs intellectual ability limits his learning.
d. The child has difficulty learning because of brain damage.
ANS: A
Learning disability is an educational term. Children with learning disabilities may have average to aboveaverage intelligence, but they may experience difficulties in perception, language, comprehension, and
conceptualization.
DIF: Cognitive Level: Comprehension REF: Page 768
TOP: Learning Disability KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life?
a. You should focus your mind on positive thoughts.
b. Everybody has a bad day now and then.
c. Youre young. What could be so terrible?
d. Tell me about the worst day of your life.
ANS: D
The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the
adolescent full attention.
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DIF: Cognitive Level: Application REF: Page 773
OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk
about that! Its none of your business, anyway! Leave me alone! How does the nurse interpret the adolescents
behavior?
a. The adolescent is acting out and needs to be brought under control so the conference can continue.
b. The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to
refocus.
c. The adolescent is demonstrating that this problem requires the assistance of a psychiatrist.
d. The adolescent is responding to the discrediting of his parents, which causes anxiety.
ANS: D
Discrediting parents threatens the childs security and creates anxiety.
DIF: Cognitive Level: Analysis REF: Page 776
OBJ: 10 TOP: Children of Alcoholics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. The nurse is answering phone calls at a local suicide prevention hotline. Which statement would be
recognized as the greatest risk of suicide?
a. I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself.
b. My parents arent home and wont be back for 4 hours. That should be enough time for the pills to work. Ive
got a hundred of them.
c. My dad will be home first, so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet.
d. My girlfriend is here with me. She told me to call because I was talking crazy about killing myself.
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ANS: B
The risk of death increases when there is a definite plan of action, the means are readily available, and the
person has few resources for help and support.
DIF: Cognitive Level: Analysis REF: Page 771
OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. A 15-year-old boy was previously active in a band and saved money to buy a special guitar. What would a
nurse assess as an early sign of depression in this boy?
a. He gives up the band to spend time with his girlfriend.
b. He spends all of his time at the library studying to qualify for the honor society.
c. He gives his guitar away and spends his time listening to music in his room.
d. He withdraws all of his money out of the bank to buy an expensive leather jacket.
ANS: C
A major depression is characterized by a prolonged behavioral change from baseline that interferes with
school, family life, and age-specific activities, frequently signaled by giving prized possessions away.
DIF: Cognitive Level: Analysis REF: Page 770
OBJ: 6 TOP: Depression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. A mother is concerned because her adolescent son is always in trouble for fighting at school and always
seems to be angry. She mentions that her husband drinks a bit. Which understanding will guide the nurses
response?
a. The boy is displaying antisocial behavior and should be evaluated for mental illness.
b. The boy is displaying one of the typical defense patterns of children of alcoholics and should receive
immediate treatment.
c. The mother is displaying her own anger witN
h UhR
erShIN
usGbTaB
nd.CsOdM
rinking, and she needs immediate intervention.
d. The boy is only one member of the family affected by alcoholism, and all members should receive
immediate intervention.
ANS: D
Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the
coping pattern of acting-out behaviors to deal with the family situation.
DIF: Cognitive Level: Comprehension REF: Page 776
OBJ: 10 TOP: Children of Alcoholics
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7. What is the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder
(ADHD) for the school nurse to suggest?
a. Seat the child in the back of the room to prevent distractions for other children.
b. Pair the child with a student buddy to offer reminders to pay attention.
c. Divide work assignments into shorter periods with breaks in between.
d. Separate the child from others to increase his focus on schoolwork.
ANS: C
The child with ADHD needs breaks between periods of work and study.
DIF: Cognitive Level: Application REF: Page 769
OBJ: 12 TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
8. How does the nurse describe a person who is bulimic?
a. Severely underweight
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b. Alternates binge eating with purging
c. Introverted perfectionist
d. Has extremely close family relationships
ANS: B
Bulimia is characterized by alternating binge eating and purge behavior.
DIF: Cognitive Level: Comprehension REF: Page 770
OBJ: 13 TOP: Bulimia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
9. A 14-year-old girl with obsessive-compulsive disorder (OCD) tells the nurse other adolescents tease her
because she washes her hands many times during the school day. For what does this disorder put the
adolescent at greater risk?
a. Anorexia nervosa
b. Depression
c. ADHD
d. A learning disability
ANS: B
OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents
with OCD.
DIF: Cognitive Level: Comprehension REF: Page 767
OBJ: 5 TOP: Obsessive-Compulsive Disorder
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. Which statement made by a parent of an adolescent with anorexia nervosa indicates an understanding of
this condition?
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a. There really isnt anything to worry about. Dont they say you can never be too thin?
b. My daughter just doesnt have much of an appetite.
c. She is just trying to punish me for divorcing her father.
d. She seems to see herself as fat, even though her weight is below normal.
ANS: D
Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes.
DIF: Cognitive Level: Comprehension REF: Page 769
OBJ: 13 TOP: Anorexia Nervosa
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
11. What is an appropriate nursing intervention for a hospitalized child who is autistic?
a. Place the child in a location where she can watch all of the activity on the unit.
b. Use the childs chronological age as a guide for communication.
c. Keep the childs room free of toys or objects that she might want to take home with her.
d. Organize care to provide as few disruptions to the routine as possible.
ANS: D
During hospitalization, the nurse should provide a highly structured environment with few distractions for a
child who is autistic.
DIF: Cognitive Level: Application REF: Page 767
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
12. A nurse is planning to speak with a parent support group about childhood autism. What will the nurse
include?
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a. Significant signs of the disorder manifest by 1 year of age.
b. The earliest signs of autism are impulsivity and overactivity.
c. Autism is usually diagnosed when the child goes to elementary school.
d. Medications can cure childhood autism.
ANS: A
Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are
significant signs of dysfunction by 1 year of age.
DIF: Cognitive Level: Comprehension REF: Page 767
TOP: Autism KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. An adolescent is brought to the emergency department after an automobile accident. When the nurse
approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic.
What does the nurse suspect the adolescent has used?
a. Alcohol
b. Cocaine
c. Amphetamines
d. PCP
ANS: A
Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness, combativeness,
and violence.
DIF: Cognitive Level: Analysis REF: Page 774
OBJ: 8 TOP: Substance Abuse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed. For what does
the nurse recognize this as the street name?
a. Barbiturates
b. Cocaine
c. Methamphetamine
d. Marijuana
ANS: C
Speed is the street name for methamphetamine.
DIF: Cognitive Level: Knowledge REF: Page 774
OBJ: 8 TOP: Substance Abuse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15. How would the nurse identify a member of the child guidance team who is a medical doctor with special
training in psychoanalytic theory?
a. Psychiatrist
b. Psychoanalyst
c. Psychologist
d. Counselor
ANS: A
The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist. The
psychologist is not a medical doctor, and neither is the counselor.
DIF: Cognitive Level: Knowledge REF: Page 766
TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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16. A young child on the pediatric unit cannot express himself well. What therapeutic intervention might the
nurse implement that allows children to act out their feelings?
a. Art therapy
b. Play therapy
c. Music therapy
d. Bibliotherapy
ANS: B
Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to
adequately express verbally.
DIF: Cognitive Level: Comprehension REF: Page 766
TOP: Play Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child. What is a
negative aspect of stimulants?
a. Sedating the child
b. Impairing cognition
c. Causing hypotension
d. Creating fluid retention
ANS: B
Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the
potential of self-injuring behavior.
DIF: Cognitive Level: Comprehension REF: Page 767
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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18. A 9-year-old has been admitted to the hospital after huffing lighter fluid and is in a high euphoric state. For
what should the nurse assess?
a. Depressed respirations
b. Severe vomiting
c. Frightening hallucinations
d. Elevation of temperature
ANS: A
Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and general sensorium.
DIF: Cognitive Level: Application REF: Page 775
TOP: Substance Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. The pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate. What action by 9-year-old
child leads the nurse to question possible dyslexia?
a. Becomes hyperactive and ceases to read
b. Reads the word dog as God
c. Makes up a story rather than reading the text
d. Stutters as he reads
ANS: B
Dyslexics often transpose a word as they read; for example, the word is dog, but it appears to the dyslexic child
as the word God.
DIF: Cognitive Level: Comprehension REF: Page 768
TOP: Dyslexia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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20. How is a gateway substance defined?
a. Recreational drug used occasionally
b. Nonaddictive drug used daily
c. Drug used to wean from stronger drugs
d. Substance that can lead to use of stronger drugs
ANS: D
A gateway drug is a substance that creates a high that can lead to the use of stronger drugs.
DIF: Cognitive Level: Knowledge REF: Page 773
OBJ: 8 TOP: Gateway Drugs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
21. Which substance puts a person at the greatest risk for HIV and hepatitis B?
a. Alcohol
b. Opiates
c. Cocaine
d. Marijuana
ANS: B
The use of opiates coupled with sharing needles put the user at risk for HIV and hepatitis B.
DIF: Cognitive Level: Comprehension REF: Page 774
OBJ: 8 TOP: Opiate Use KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22. What role has the child of an alcoholic assumed if he tries to do everything perfectly?
a. Perfect child
b. Super coper
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c. Flight
d. Helper
ANS: B
Of the four roles for the child of the alcoholic, the super coper is one who tries to do everything perfectly and
feels overly responsible. The perfect child is the child who tries to earn love by never causing any trouble.
DIF: Cognitive Level: Comprehension REF: Page 776
OBJ: 10 TOP: Child of an Alcoholic
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
MULTIPLE RESPONSE
23. The nurse working with children from dysfunctional families must be prepared to address what associated
problem(s)? (Select all that apply.)
a. Lack of trust
b. Acting out
c. Exaggerated self-confidence
d. Blaming others for problems
e. Depression
ANS: A, B, E
Children from dysfunctional families exhibit lack of trust, act out, and show signs of depression.
DIF: Cognitive Level: Comprehension REF: Page 766
TOP: Dysfunctional Families KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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24. The nurse counsels parents that the early school years create nervous tension in the child manifested by
which abnormal behavior(s)? (Select all that apply.)
a. Masturbation
b. Food fads
c. Stuttering
d. Aggressive behavior
e. Nonnutritive sucking
ANS: C, D, E
Stuttering, aggressive behavior, and finger or thumb sucking that appear suddenly with no previous history are
a clue to increased nervous tension in the young school-age child. Masturbation and food fads are normal
behavioral phenomena for the early school-age child.
DIF: Cognitive Level: Comprehension REF: Page 767
TOP: Nervous Tension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
25. The nurse states that the members of a mental health team for child guidance include which member(s)?
(Select all that apply.)
a. Psychiatrist
b. Pediatrician
c. Psychologist
d. Dietitian
e. Social worker
ANS: A, B, C, E
The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social
worker. The dietitian is not usually on the treatment team.
DIF: Cognitive Level: Knowledge REF: PageN7U
66RSINGTB.COM
TOP: Members of the Child Guidance Team
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
26. The school nurse cautions a group of parents about the prevalence of children who get high by inhaling
hydrocarbons and fluorocarbons. Which products contain these substances? (Select all that apply.)
a. Glue
b. Chlorine
c. Cleaning fluid
d. Copy machine toner
e. Aerosol sprays
ANS: A, C, E
Although there are many products that could be inhaled, the most frequently used products are glue, cleaning
fluid, aerosol sprays, Freon, shoe polish, and gasoline products.
DIF: Cognitive Level: Knowledge REF: Page 774
OBJ: 8 TOP: Inhaling Hydrocarbons
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27. The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s) cause this
disorder? (Select all that apply.)
a. Discomfort relative to emerging sexuality
b. Fear of intimacy
c. Pervasive high self-esteem
d. Egocentricity
e. Inability to meet developmental needs
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ANS: A, B, D, E
All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa. Pervasive low
self-esteem also is considered a cause of anorexia nervosa.
DIF: Cognitive Level: Comprehension REF: Page 769
TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28. The nurse is assessing a 16-year-old female for characteristics of anorexia nervosa. Which assessment
finding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply.)
a. Amenorrhea
b. Severe weight loss
c. Oily skin
d. Hypertension
e. Lanugo on back
ANS: A, B, E
The primary symptom of anorexia nervosa is severe weight loss. Adolescents who wish to be fashion models
or actresses or who participate in sports, dance, or gymnastics activities may be at risk for developing an eating
disorder. On physical examination, some of the following conditions may be evident: dry skin, amenorrhea,
lanugo hair over the back and extremities, cold intolerance, low blood pressure, abdominal pain, and
constipation.
DIF: Cognitive Level: Comprehension REF: Page 769
TOP: Anorexia Nervosa KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29. A nurse is hired to work in a psychiatric facility on a unit specializing in obsessive compulsive disorders
(OCD). Which diagnoses might the nurse expect to encounter? (Select all that apply.)
a. Trichotillomania
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b. Hoarding disorder
c. Excoriation disorder
d. Body dysmorphic disorder
e. Oppositional defiant disorder
ANS: A, B, C, D
Oppositional defiant disorder is described as an ongoing pattern of anger-guided disobedience, a hostile or
defiant response to authority and is not considered a form of OCD.
DIF: Cognitive Level: Knowledge REF: Page 768
TOP: Obsessive Compulsive Disorder KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
30. A child is diagnosed with attention deficit hyperactivity disorder (ADHD). Which characteristics would the
nurse assess in this child? (Select all that apply.)
a. Social anxiety
b. Impulsivity
c. Hyperactivity
d. Distractability
e. Inattention
ANS: B, C, D, E
ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.
DIF: Cognitive Level: Knowledge REF: Page 768
TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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COMPLETION
31. The nurse documents that every time the child is directed to discuss the relationship with her brother, she
complains of shortness of breath and begins to have asthma-like symptoms. The nurse assesses this behavior as
a(n)
reaction.
ANS:
psychosomatic
A psychosomatic reaction is one in which a dysfunction of the body has an emotional or mental cause.
DIF: Cognitive Level: Comprehension REF: Page 767
TOP: Psychosomatic Reaction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
32. The nurse assists with the intervention of
environment that is stable and therapeutic.
therapy, which provides a physical and social
ANS:
milieu
Milieu therapy is a modality of treatment offered to troubled children, in which they are placed in an
environment that is stable and therapeutic so that their problems might be better expressed or identified.
DIF: Cognitive Level: Knowledge REF: Page 766
TOP: Milieu Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
33. Early childhood experiences are critical to personality formation. Situations that disrupt family patterns can
have a lasting impact on the child. These families are known as
and can make children feel
negatively about themselves and the world. NURSINGTB.COM
ANS:
dysfunctional
Early childhood experiences are critical to personality formation. Situations that disrupt family patterns can
have a lasting impact on the child. Children who come from these dysfunctional families may experience any
of the following: failure to develop a sense of trust (in their caregivers and environment), excessive fears,
misdirected anger manifested as behavioral problems, depression, low self-esteem, lack of confidence, and
feelings of lack of control over themselves and their environment.
Cognitive Level: Knowledge
DIF: Cognitive Level: Knowledge REF: Page 766
TOP: Suicide KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment
34. Put the 5 steps of the SAFE-T program in the correct order. Put a comma and space between each answer
choice (a, b, c, d, etc.)
a. Determine risk level
b. Document and follow up
c. Identify risk
d. Identify protective factors
e. Suicide inquiry
ANS:
C, D, E, A, B
The order of the SAFE-T program is to first identify risk (warning signs); second,
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identify protective factors (coping strategies; support persons); third, suicide inquiry (identify plans); fourth,
determine risk level (interventions); and last, to document and follow up.
DIF: Cognitive Level: Comprehension REF: Page 773
TOP: Suicide
KEY: Nursing Process Step: Data Collection | Nursing Process Step: Intervention | Nursing Process Step:
Evaluation MSC: NCLEX: Psychosocial Integrity: Crisis Intervention
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Chapter 34: Complementary and Alternative Therapies in Maternity and
Pediatric Nursing
MULTIPLE CHOICE
1. A pregnant woman tells the nurse that she got relief from nausea when she had a therapy that involves
pressure and massage on meridian sites. What type of therapy does this describe?
a. Acupuncture
b. Acupressure
c. Aromatherapy
d. Ayurveda
ANS: B
Acupressure uses finger pressure and massage on the meridian sites. It can be used during pregnancy to control
nausea, backache, and pain. It has been useful for minor postpartum problems such as constipation.
DIF: Cognitive Level: Knowledge REF: Page 783
OBJ: 2 TOP: Acupressure KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Which child should not receive massage therapy?
a. 15-year-old with a fractured femur
b. 12-year-old with diabetes mellitus
c. 8-year-old with Down syndrome
d. 17-year-old with an eating disorder
ANS: C
Children with Down syndrome are prone particularly to cervical spine anomalies and may be injured by
massage therapy.
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DIF: Cognitive Level: Comprehension REF: Page 782
TOP: Massage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. A 12-year-old with rheumatoid arthritis finds aromatherapy helpful for relieving her joint discomfort. Which
essential oil is useful for children with chronic pain?
a. Lavender
b. Ephedra
c. Ginseng
d. Kava-kava
ANS: A
Lavender, chamomile, and sandalwood essential oils are useful in aromatherapy for children with chronic pain.
DIF: Cognitive Level: Knowledge REF: Page 784
OBJ: 2 TOP: Alternative Health PracticesAromatherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. A pregnant woman wishes to use aromatherapy during her labor and delivery. What is the most appropriate
essential oil for the nurse to recommend?
a. Juniper
b. Wintergreen
c. Thyme
d. Citrus
ANS: D
Citrus is one essential oil that has been shown to be useful during labor and delivery.
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DIF: Cognitive Level: Comprehension REF: Page 784
TOP: Aromatherapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A parent asks the nurse, What is guided imagery? Which statement is the most accurate response?
a. It is a technique where the patient focuses on an image to relieve stress.
b. It involves using water to promote relaxation.
c. The patient enters a hypnotic state of sleep to promote relaxation.
d. It helps the patient recognize tension in the muscles with responses on an electronic machine.
ANS: A
In guided imagery, by focusing on a specific image, stress reduction and improved performance can result.
DIF: Cognitive Level: Knowledge REF: Page 784
TOP: Guided Imagery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. A woman taking St. Johns wort and ginseng daily is scheduled to have a hysterectomy in 3 weeks. What
instruction should the nurse provide?
a. The herbs are not likely to cause any problems during the surgery.
b. The St. Johns wort must be stopped prior to surgery, but she can continue the ginseng.
c. The ginseng should be stopped 1 week before surgery.
d. She should discontinue taking both herbs 2 weeks before surgery.
ANS: D
Both St. Johns wort and ginseng can cause problems during surgery, and their use should be discontinued 2
weeks before surgery.
DIF: Cognitive Level: Application REF: Page 781
OBJ: 6 TOP: Herbal Remedies
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
7. Which herb can the nurse suggest to be used for discomforts associated with menopause, such as hot
flashes?
a. Evening primrose oil
b. Echinacea
c. Milk thistle
d. Black cohosh
ANS: D
Black cohosh diminishes hot flashes by reducing luteinizing hormone. It also reduces joint pain and other
menopausal discomforts.
DIF: Cognitive Level: Knowledge REF: Page 788
OBJ: 12 TOP: Herbal Remedies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8. A young mother asks, Is there an alternative medicine for children with asthma? Which form of alternative
medicine would be the most helpful for the nurse to suggest?
a. Reflexology
b. Rolfing
c. Guided imagery
d. Acupressure
ANS: C
The use of guided imagery has helped relieve some of the symptoms of asthma.
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DIF: Cognitive Level: Comprehension REF: Page 779
TOP: Guided Imagery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. What is the difference between complementary therapy and alternative therapy?
a. Complementary therapy must be administered by a medical doctor.
b. Complementary therapy is administered with conventional therapy.
c. Complementary therapy replaces conventional therapy.
d. Complementary therapy is administered to a group of patients at the same time.
ANS: B
Complementary therapy is administered with conventional therapy, such as massage with muscle relaxants for
low back pain.
DIF: Cognitive Level: Comprehension REF: Page 779
TOP: CAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The nurse uses a diagram to show the location of meridians. How will the nurse explain the definition of
meridians?
a. They are lymph nodes.
b. They are invisible pathways for energy.
c. They are lines that divide the body into 10 zones.
d. They are areas of skin that are specifically innervated.
ANS: B
Meridians are invisible pathways through which energy travels to effect acupuncture treatment.
DIF: Cognitive Level: Knowledge REF: Page 783
OBJ: 8 TOP: Herbal Remedies: CAM
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. Which herbal remedy used by a patient taking warfarin should the nurse report to the physician?
a. Angelica (dong quai)
b. Chamomile
c. Ginseng
d. Kava-kava
ANS: A
Angelica prolongs prothrombin time and will synergize the effect of the warfarin.
DIF: Cognitive Level: Application REF: Page 785
OBJ: 4 TOP: Herbal Remedies
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. What should the nurse remind a parent who is considering homeopathic remedies for treatment of her
childs asthma?
a. Should be drunk with large amounts of fluid
b. Can be taken with traditional Western medications
c. Can be enhanced by drinking hot tea
d. May contain mercury, alcohol, or arsenic
ANS: D
Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually. All Western
medications should be stopped when the homeopathic therapy is begun. Caffeine drinks are to be avoided
during homeopathic treatment.
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DIF: Cognitive Level: Application REF: Page 784
TOP: Homeopathic Remedies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13. The focus of acupressure is to restore the balance of what?
a. Chi
b. Shiatsu
c. Yin and yang
d. Ayurveda
ANS: A
Acupressure is focused on the return of the balance of Chi to control disease processes.
DIF: Cognitive Level: Comprehension REF: Page 783
TOP: Acupressure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
14. A breastfeeding mother tells the nurse she is taking large doses of vitamin C to keep up her energy. What
should the nurse warn that large doses of vitamin C can cause in an infant?
a. Diarrhea
b. Jaundice
c. Colic
d. Retinal damage
ANS: C
Vitamin C can be passed on to a breastfeeding child through breast milk and can cause colic.
DIF: Cognitive Level: Comprehension REF: Page 786
TOP: Vitamin C KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: PharmNaUcR
olSoIgNicGaTl BT.hCeOraMpies
15. The pregnant patient with a stasis ulcer asks if she might be a candidate for hyperbaric oxygen therapy
(HBOT). What is the nurses best response?
a. Yes. Hyperbaric oxygen therapy should have no harmful effect on your baby.
b. No. High amounts of oxygen in your system will cause changes in your babys heart.
c. Yes. Hyperbaric oxygen therapy is a much better option than using antibiotics.
d. No. Hyperbaric oxygen therapy may cause the placenta to separate from the uterine wall.
ANS: B
High concentrations of oxygen in the mothers blood can cause closure of the ductus arteriosus and cause fetal
death.
DIF: Cognitive Level: Application REF: Page 788
TOP: HBOT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16. A patient is providing history information to the admitting nurse about treatment used for chronic pain. The
patient reports she participates in a type of relaxation therapy that enables her to recognize tension in the
muscles via responses on an electronic machine and visual electromyography responses. What type of therapy
does the nurse record on admission record?
a. Guided imagery
b. Biofeedback
c. Hypnotherapy
d. Chiropractic care
ANS: B
Biofeedback is a type of relaxation therapy that enables the patient to recognize tension in the muscles via
responses on an electronic machine and visual electromyography responses. The process is also used by
traditional health care providers for drug addiction and chronic pain control.
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DIF: Cognitive Level: Comprehension REF: Page 784
TOP: CAM Therapies KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
17. What conditions would a nurse expect to see treated with hyperbaric oxygen therapy (HBOT)? (Select all
that apply.)
a. Wounds
b. Carbon monoxide poisoning
c. Hyperemesis gravidarum
d. Decompression illness
e. Pneumonia
ANS: A, B, D
Hyperbaric oxygen therapy (HBOT) uses an airtight enclosure to provide compressed air or oxygen under
increased pressure. HBOT is used to revive children with carbon monoxide poisoning, to aid wound healing,
and to treat the diving syndrome known as decompression illness. HBOT is contraindicated during pregnancy,
because the increased oxygen saturation can cause the ductus arteriosus to close, resulting in fetal death.
DIF: Cognitive Level: Knowledge REF: Page 788
TOP: HBOT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18. The mother of a pediatric patient asks the nurse about safety concerns with using herbal supplements with
children. Which herbal products would the nurse educate this mother are safe to use in most of the pediatric
population? (Select all that apply.)
a. Ephedra
b. Ginger
c. Fish oil
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d. Chamomile
e. Aloe vera
ANS: B, C, D, E
Ginger, fish oil, chamomile and aloe vera are safe herbal products for children. However, some herbs, such as
ephedra, can be fatal to children.
DIF: Cognitive Level: Knowledge REF: Page 786
OBJ: 11 TOP: Herbal Therapies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19. The nurse points out that light therapy is used in the treatment of patients with which disorder(s)? (Select
all that apply.)
a. Digestive disorders
b. Seasonal affective disorder
c. Inflammatory diseases
d. Stress disorders
e. Jaundice
ANS: B, E
Light therapy has proven effective in the treatment of persons with seasonal affective disorders. Light therapy
is also used in the treatment of jaundiced babies.
DIF: Cognitive Level: Comprehension REF: Page 782
TOP: Light Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. What advantage(s) of alternative health care should the nurse outline when providing information to
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patients? (Select all that apply.)
a. Offering more patient control of health care
b. Offering a variety of health care advisors
c. Keeping patients from having to make decisions
d. Using natural products rather than chemical ones
e. Incorporating cultural beliefs and practices
ANS: A, B, D, E
Alternative health care actually promotes the patients decision making in care.
DIF: Cognitive Level: Comprehension REF: Page 779
OBJ: 5 TOP: CAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. Which approaches to care are combined with osteopathy? (Select all that apply.)
a. Manipulation therapy
b. Aroma therapy
c. Herbal application
d. Pressure point therapy
e. Traditional medicine
ANS: A, D, E DIF: Cognitive Level: Knowledge REF: Page 782
OBJ: 9 TOP: Osteopathy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
22. The practice of
ANS:
rolfing
is a process of fascia pressure and stretching.
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Rolfing involves a process of stretching and placing pressure on the fascia to improve muscle and bone
function.
DIF: Cognitive Level: Knowledge REF: Page 782
TOP: Rolfing KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. While taking care of a Navajo child, the nurse welcomes their folk healer, called a
.
ANS:
singer
The Navajo recognize persons in their tribe as folk healers called singers. These persons perform rites for
healing and well-being that are comforting to the Navajo.
DIF: Cognitive Level: Knowledge REF: Page 780
TOP: Navajo Practices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
24. The nurse clarifies that a person who is
respect for different practices and philosophies.
demonstrates sensitivity and
ANS:
culturally competent
The culturally competent nurse shows sensitivity, respect, and an open attitude to the health care needs of other
cultures.
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DIF: Cognitive Level: Comprehension REF: Page 780
TOP: Cultural Competency KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
25. The nurse explains that
are areas of skin that are innervated by the dorsal roots of the
spinal cord, which are the basis of acupressure therapy.
ANS:
dermatomes
Dermatomes are areas of the skin that are innervated by the dorsal roots of the spinal cord. Pressure in these
areas is the basis of acupressure therapy.
DIF: Cognitive Level: Knowledge REF: Page 783
OBJ: 8 TOP: Dermatomes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
26.
is an ancient practice that involves concentrated fluid or the essence of specific herbs
that are combined with steams or baths to inhale or bathe the skin.
ANS:
Aromatherapy
Aromatherapy is an ancient practice that involves concentrated fluid or the essence of specific herbs that are
combined with steams or baths to inhale or bathe the skin.
DIF: Cognitive Level: Knowledge REF: Page 784
TOP: Aromatherapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
NU
27. In 1992 the National Institutes of Health (N
IHR)ScIrNeG
atTeB
d .tChO
eM
Office of Alternative Medicine to evaluate the
various CAM therapies. It has since been renamed
the
.
ANS:
National Center for Complementary and Alternative Medicine (NCCAM)
In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the
various CAM therapies. It has since been renamed the National Center for Complementary and Alternative
Medicine (NCCAM). This Center serves as a public clearinghouse and resource for research concerning CAM
therapies.
DIF: Cognitive Level: Knowledge REF: Page 780
TOP: NIH KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Self-Care
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