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Study MaterialMaterial
Chapter 01: The Past, Present, and Future
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A patient chooses to have the certified nurse-midwife (CNM) provide care during her
pregnancy. What does the CNM‘s scope of practice include?
Practice independent from medical supervision
Comprehensive prenatal care
Attendance at all deliveries
Cesarean sections
a.
b.
c.
d.
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: p. 6
OBJ: 5
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?
Karl Credé
Ignaz Semmelweis
Louis Pasteur
Joseph Lister
a.
b.
c.
d.
ANS: B
Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by
the unwashed hands of physicians and medical students.
DIF: Cognitive Level: Knowledge
REF: p. 2
OBJ: 1
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: pp. 6-8
OBJ: 8
TOP: Cross-Cultural Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation
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Study MaterialMaterial
4. An urban area has been reported to have a high perinatal mortality rate. What information
does this provide?
Maternal and infant deaths per 100,000 live births per year
Deaths of fetuses weighing more than 500 g per 10,000 births per year
Deaths of infants up to 1 year of age per 1000 live births per year
Fetal and neonatal deaths per 1000 live births per year
a.
b.
c.
d.
ANS: D
The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.
DIF: Cognitive Level: Comprehension
REF: p. 13 | Box 1.6
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: p. 6
OBJ: 5
TOP: The Present-Maternity Care
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
6. Who advocated the establishment of the Children‘s 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 Children‘s Bureau.
DIF: Cognitive Level: Knowledge
REF: p. 4
OBJ: 1 | 2
TOP: The Past
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. What was the result of research done in the 1930s by the Children‘s 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. Children‘s asylums were founded.
ANS: C
School hot lunch programs were developed as a result of research by the Children‘s Bureau on
the effects of economic depression on children.
DIF: Cognitive Level: Knowledge
REF: p. 4
OBJ: 2 | 3
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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?
WIC
Title XIX of Medicaid
The Children‘s Charter
Head Start
a.
b.
c.
d.
ANS: D
Head Start programs were established to increase educational exposure of preschool children.
DIF: Cognitive Level: Knowledge
REF: p. 3
OBJ: 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?
Clinical pathways
Nursing outcome criteria
Standards of care
Nursing care plan
a.
b.
c.
d.
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: p. 13
OBJ: 10
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 child‘s medical diagnosis.
ANS: C
The nurse uses assessment data to select appropriate nursing diagnoses. Outcomes and
interventions are then developed to address the relevant nursing diagnoses.
DIF: Cognitive Level: Application
REF: p. 12
OBJ: 7
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 nurse suggest to the student?
a. American Nurses Association
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b. State‘s Board of Nursing
c. Joint Commission
d. Association of Women‘s Health, Obstetric and Neonatal Nurses
ANS: B
The scope of practice of the LVN/LPN is published by the state‘s board of nursing.
DIF: Cognitive Level: Comprehension
REF: p. 16
OBJ: 2
TOP: Critical Thinking
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
12. What was recommended by Karl Credé 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 Credé recommended the use of 2% silver nitrate in the eyes of newborns to
reduce the incidence of blindness.
DIF: Cognitive Level: Knowledge
REF: p. 2
OBJ: 1
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.
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: p. 4
OBJ: 2
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?
24
48
36
72
a.
b.
c.
d.
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: p. 6
TOP: Hospital Terms for Postpartum Patients
KEY: Nursing Process Step: Planning
OBJ: 5
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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
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: p. 13
OBJ: 10
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 nurse‘s best
response?
Gene therapy can replace missing genes.
Gene therapy evaluates the parent‘s genes.
Gene therapy can change the sex of the fetus.
Gene therapy supports the regeneration of defective genes.
a.
b.
c.
d.
ANS: A
Gene therapy can replace missing or defective genes.
DIF: Cognitive Level: Knowledge
REF: p. 8
OBJ: 5
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 nurse‘s best response when the patient asks how DRGs reduce medical care costs?
By determining payment based on diagnosis
By requiring two medical opinions to confirm a diagnosis
By organizing HMOs
By defining a person who will require hospitalization
a.
b.
c.
d.
ANS: A
DRGs determine the amount of payment and length of hospital stay based on the diagnosis.
DIF: Cognitive Level: Comprehension
REF: p. 8
OBJ: 3
TOP: DRGs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
18. 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: pp. 16-17
OBJ: 12
TOP: Computer Charting
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19. 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: p. 1
OBJ: 13
TOP: Empowerment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20. 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
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: p. 3
OBJ: 5
TOP: FMLA
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. 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
TOP: Cultural Competency
REF: p. 6
OBJ: 6
KEY: Nursing Process Step: N/A
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MSC: NCLEX: N/A
22. 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
ANS: D
Critical thinking results in problem prevention in designing nursing care.
DIF: Cognitive Level: Comprehension
TOP: Critical Thinking
MSC: NCLEX: N/A
REF: p. 15
OBJ: 11
KEY: Nursing Process Step: N/A
MULTIPLE RESPONSE
1. 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
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: p. 6
OBJ: 5
TOP: Birthing Centers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
2. What developments in the early 20th century encouraged women to seek hospitalization for
childbirth? (Select all that apply.)
Use of specialized obstetric instruments
Use of anesthesia
Physicians‘ closer relationships with hospitals
Focus on family-centered care
Insurance coverage
a.
b.
c.
d.
e.
ANS: A, B, C
In the early 1900s, the development of specialized obstetric instruments, better modes of
anesthesia, and the physician‘s reliance on hospital services were instrumental in encouraging
women to seek hospitalization for childbirth.
DIF: Cognitive Level: Comprehension
REF: pp. 2-3
OBJ: 5
TOP: Hospitalization for Childbirth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. What non–family-centered policies were prevalent in the 1960s? (Select all that apply.)
a. Waiting room for fathers
b. Sedation of mother during labor
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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: p. 3
OBJ: 5
TOP: Non–Family-Centered Practices
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4. 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.)
Tuberculosis
Child abuse
Industrial accidents
Sexually transmitted diseases
Foodborne infections
a.
b.
c.
d.
e.
ANS: A, B, D, E
The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and
sexually transmitted diseases), foodborne infections, child abuse, and threats of suicide.
DIF: Cognitive Level: Comprehension
REF: p. 4 | Legal and Ethical Considerations Box
OBJ: 4
TOP: Reportable Diseases
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. 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.)
Memorization of facts first
Prioritizing information
Relating facts to other facts
Making assumptions
Reviewing before the test
a.
b.
c.
d.
e.
ANS: B, C, E
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: p. 16
OBJ: 8
TOP: Critical Thinking
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment
6. What factors have played a role in meeting the goals of Healthy People 2030 as it relates the
goals for outcomes of pregnancy? (Select all that apply.)
a. Early prenatal care
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b.
c.
d.
e.
Increased number of surgical births
NICU care
Use of prenatal glucocorticoids
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 2030 may well be met. Increase in surgical births and multiple gestations do not work
toward meeting the goals of Healthy People 2030.
DIF: Cognitive Level: Comprehension
REF: p. 17
OBJ: 13
TOP: Healthy People 2030
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
7. 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.)
Glucose monitoring
Heparin therapy
Family education
Total parenteral nutrition
Provision of referral services
a.
b.
c.
d.
e.
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: p. 20
OBJ: 14
TOP: Community Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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Chapter 02: Human Reproductive Anatomy and Physiology
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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.
b.
c.
d.
Stimulation of production of white cells and platelets
Promotion of growth of small bones
Increase in muscle mass and strength
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: p. 25
OBJ: 1 | 2 | 5
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: p. 24
OBJ: 3 | 5
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?
Infrequent sexual intercourse
The man not being circumcised
The penis and testes being small
The testes being too warm
a.
b.
c.
d.
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: p. 25
OBJ: 3
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
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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: p. 27
OBJ: 7
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?
Menarche usually occurs around 12 years of age.
Ovulation occurs regularly from the very first cycle.
A regular cycle is established by the third period.
Typically, menstrual flow is heavy and lasts up to 10 days.
a.
b.
c.
d.
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: p. 30
OBJ: 1 | 9
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: p. 24
OBJ: 1 | 2
TOP: Puberty—Female
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. A 12-year-old female patient experienced menarche 3 months ago. Her mother voices concern
to the pediatric office nurse regarding the irregularity of her daughter‘s menstrual cycle. What
is the nurse‘s 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.
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DIF: Cognitive Level: Application
REF: p. 30
OBJ: 9
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: p. 30
OBJ: 1 | 9
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: p. 28
OBJ: 9
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?
Gynecoid
Android
Anthropoid
Platypelloid
a.
b.
c.
d.
ANS: A
The gynecoid pelvis is the typical female pelvis and is most favorable for vaginal birth.
DIF: Cognitive Level: Knowledge
REF: p. 28
OBJ: 8
TOP: Female Reproductive System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention 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
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of milk.
ANS: A
Breast size does not influence the ability to secrete milk.
DIF: Cognitive Level: Comprehension
REF: p. 30
OBJ: 6
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: p. 30
OBJ: 9
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 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: p. 29
OBJ: 8
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?
“Periods last about 5 days.”
“My cycle should get regular in 6 months.”
“I should expect heavy bleeding with clots.”
“Periods come about every 4 weeks.”
a.
b.
c.
d.
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: p. 30
OBJ: 9
TOP: Female Reproductive Cycle
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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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 with puberty?
a. “Your daughter will have her first period.”
b. “You‘ll 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: p. 23
OBJ: 1 | 2
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?
“Fertilization of an ovum requires penetration by several sperm.”
“An ovum must be fertilized within 24 hours of ovulation.”
“It takes 4 to 5 days for sperm to reach the fallopian tubes.”
“Sperm live for only 24 hours following ejaculation.”
a.
b.
c.
d.
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: p. 32
OBJ: 6 | 7
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 statement made by the man indicates an understanding about sexual activity
and pregnancy?
a. “My wife can‘t get pregnant if I withdraw before climax.”
b. “A man can secrete semen before ejaculation.”
c. “If we don‘t have intercourse very often, my wife won‘t 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: p. 25
OBJ: 4
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 cm. 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
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ANS: A
The obstetric conjugate is approximately 1.5 to 2 cm shorter than the diagonal conjugate.
DIF: Cognitive Level: Knowledge
REF: p. 29
OBJ: 1 | 8
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?
They form the passageway for the sperm to meet the ovum.
They are the site of fertilization.
They are fingerlike projections that “capture” the ovum.
They propel the egg through the fallopian tube.
a.
b.
c.
d.
ANS: C
Fimbriae are the fingerlike projections from the infundibulum that “capture” the ovum at
ovulation and conduct it into the fallopian tube.
DIF: Cognitive Level: Comprehension
REF: p. 28
OBJ: 6 | 7
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 drop in testosterone level
Sexual stimulation
Absence of sperm in ejaculate
Association with violent dreams
a.
b.
c.
d.
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: p. 24
OBJ: 2
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?
Lactiferous sinuses
Lobes
Montgomery‘s glands
Alveoli lobules
a.
b.
c.
d.
ANS: D
The alveoli secrete milk.
DIF: Cognitive Level: Knowledge
REF: p. 30
OBJ: 6 | 7
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?
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a.
b.
c.
d.
Vas deferens
Epididymis
Cowper‘s gland
Scrotum
ANS: C
The Cowper‘s gland secretions nourish the sperm.
DIF: Cognitive Level: Knowledge
REF: p. 25
OBJ: 4
TOP: Cowper‘s 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.
ANS: D
Puberty ends for a male when mature sperm are formed by the testes.
DIF: Cognitive Level: Knowledge
REF: p. 23
OBJ: 1 | 2
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: p. 32
OBJ: 5
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?
Maternal antibodies
Stimulus for red blood cell production
Endorphins that soothe the infant
Hormones that stimulate growth
a.
b.
c.
d.
ANS: A
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: p. 29
OBJ: 7
TOP: Properties of Breast Milk
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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26. A female patient reports her menstrual cycle consistently occurs every 32 days. What day of
her cycle can the woman anticipate ovulation?
14
16
18
20
a.
b.
c.
d.
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: p. 30
OBJ: 9
TOP: Menstrual Cycle
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. 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
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: p. 23
OBJ: 2
TOP: Rites of Passage
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. The nurse is reading a pregnant patient‘s history and physical. What information does the
nurse recognize might indicate the need for a cesarean delivery? (Select all that apply.)
History of childhood rickets
Immobile coccyx
Prepregnant weight of 100 pounds
Avid horse rider
Pelvic fracture 3 years ago
a.
b.
c.
d.
e.
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: pp. 28-29
TOP: Pelvic Conditions Predisposing Cesarean Delivery
KEY: Nursing Process Step: Data Collection
OBJ: 8
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What are considered to be functions of the fallopian tubes? (Select all that apply.)
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: p. 28
OBJ: 7
TOP: Function of Fallopian Tubes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse is providing an in-service 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: p. 28
OBJ: 6 | 8
TOP: Bones of the Pelvis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. The nurse explains that testosterone is responsible for males exceeding females in which
aspects? (Select all that apply.)
Strength
Height
Mental concentration
Hematocrit levels
Agility
a.
b.
c.
d.
e.
ANS: A, B, D
Testosterone has the following effects not directly related to sexual reproduction: increases
muscle mass and strength, promotes growth of long bones, increases basal metabolic rate,
enhances production of red blood cells, produces enlargement of vocal cords, and affects the
distribution of body hair. These effects result in greater strength and stature and a higher
hematocrit level in males than in females.
DIF: Cognitive Level: Knowledge
REF: p. 25
OBJ: 2
TOP: Effects of Testosterone
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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6. 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: p. 26
OBJ: 7
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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Chapter 03: Fetal Development
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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 cells) contain 23 chromosomes.
DIF: Cognitive Level: Knowledge
REF: p. 34
OBJ: 2
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: p. 36
OBJ: 3
TOP: Sex Determination
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. What is the most common site for fertilization?
a.
b.
c.
d.
Lower segment of the uterus
Outer third of the fallopian tube near the ovary
Upper portion of the uterus
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: pp. 35-36
OBJ: 3
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
TOP: Prenatal Developmental Milestones
REF: p. 39
OBJ: 4
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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?
One umbilical vein
Two umbilical veins
One umbilical artery
Two umbilical arteries
a.
b.
c.
d.
ANS: A
The umbilical vein transports richly oxygenated blood from the placenta to the fetus.
DIF: Cognitive Level: Knowledge
REF: p. 43
OBJ: 7
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: p. 38
OBJ: 3
TOP: Implantation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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7. What is the embryonic membrane that contains fingerlike projections on its surface, which
attach to the uterine wall?
Amnion
Yolk sac
Chorion
Decidua basalis
a.
b.
c.
d.
ANS: C
The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.
DIF: Cognitive Level: Knowledge
REF: p. 38
OBJ: 4
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?
Estrogen
Human chorionic gonadotropin
Human placental lactogen
Progesterone
a.
b.
c.
d.
ANS: D
At high levels, progesterone maintains the endometrial lining for implantation of the zygote.
DIF: Cognitive Level: Knowledge
REF: p. 42
OBJ: 6
TOP: Placenta
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. A pregnant patient asks the nurse when her infant‘s heart will begin to pump blood. What will
the nurse reply?
By the end of week 3
Beginning in week 8
By the end of week 16
Beginning in week 24
a.
b.
c.
d.
ANS: A
The fetal heart begins to pump by week 3 of gestation.
DIF: Cognitive Level: Knowledge
REF: p. 43
OBJ: 5
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.
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DIF: Cognitive Level: Knowledge
REF: p. 43
OBJ: 7
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.
DIF: Cognitive Level: Comprehension
REF: p. 43
OBJ: 7
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?
Dizygotic twins
Monozygotic twins
Conjoined twins
High–birth weight twins
a.
b.
c.
d.
ANS: A
Dizygotic twins always have two amnions and two chorions (placentas).
DIF: Cognitive Level: Comprehension
REF: p. 45
OBJ: 8
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?
Lanugo covering the body
Constant motion
Skin that is pink and smooth
Eyes that are closed
a.
b.
c.
d.
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.
DIF: Cognitive Level: Comprehension
REF: p. 41 | Table 3.1
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
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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: p. 41 | Table 3.1
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 doctor‘s 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.
DIF: Cognitive Level: Knowledge
REF: p. 42
OBJ: 6
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?
Congenital heart defects
Neural tube defects
Mental retardation
Premature birth
a.
b.
c.
d.
ANS: B
It is now known that folic acid supplements can prevent neural tube defects such as spina
bifida.
DIF: Cognitive Level: Comprehension
REF: p. 39
OBJ: 5
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?
14 weeks
20 weeks
25 weeks
30 weeks
a.
b.
c.
d.
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: p. 39
OBJ: 5
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: p. 37
OBJ: 4
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?
Inadequate space in the uterus
Inadequate blood supply
Inadequate maternal health
Inadequate placental nutrition
a.
b.
c.
d.
ANS: D
The single placenta may not be able to provide adequate nutrition to two fetuses.
DIF: Cognitive Level: Comprehension
REF: p. 45
OBJ: 8
TOP: Low Birth-Weight Twins
KEY: Nursing Process Step: Implementation
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: p. 36
OBJ: 3
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?
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a.
b.
c.
d.
Age
Estrogen level
Body temperature
Level of feminine hygiene
ANS: B
Estrogen levels and the pH of the female reproductive tract can affect the survival of the Xand Y-bearing sperm as well as their motility.
DIF: Cognitive Level: Knowledge
REF: p. 36
OBJ: 3
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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: p. 43
OBJ: 6
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: p. 39 | Box 3.1
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 first expect to see the 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
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The fetal period begins at the 9th week, and by the 10th week the external genitalia are visible
to ultrasound examination.
DIF: Cognitive Level: Knowledge
REF: p. 39
OBJ: 5
TOP: Fetal Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. 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.)
Ectoderm
Endoderm
Mesoderm
Plastoderm
Blastoderm
a.
b.
c.
d.
e.
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: p. 39 | Box 3.1
OBJ: 4
TOP: Primary Germ Layers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. 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: p. 38
OBJ: 6
TOP: Amniotic Fluid
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. 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.
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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 increases with maternal age.
DIF: Cognitive Level: Comprehension
REF: p. 45
OBJ: 8
TOP: Dizygotic Twins
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. 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: p. 38
OBJ: 6
TOP: Amniotic Fluid
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 04: Prenatal Care and Adaptations to Pregnancy
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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 patient‘s 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: p. 51 | Box 4.1
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 weeks
through 36 weeks. From 36 weeks until delivery, visits are weekly.
DIF: Cognitive Level: Application
REF: p. 49
OBJ: 2 | 3
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 Chadwick‘s sign is
present. What is Chadwick‘s sign?
Bluish or purplish discoloration of the vulva, vagina, and cervix
Presence of early fetal movements
Darkening of the areola and breast tenderness
Palpation of the fetal outline
a.
b.
c.
d.
ANS: A
Chadwick‘s sign is the purplish or bluish discoloration of the cervix, vulva and vagina.
DIF: Cognitive Level: Knowledge
REF: p. 53
OBJ: 7
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 Chadwick‘s sign occurs
during pregnancy. What would the nurse explain as the cause of Chadwick‘s sign?
a. Enlargement of the uterus
b. Progesterone action on the breasts
c. Increasing activity of the fetus
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d. Vascular congestion in the pelvic area
ANS: D
Chadwick‘s sign is caused by increased vascular congestion in the cervical and vaginal area.
DIF: Cognitive Level: Comprehension
REF: p. 53
OBJ: 6 | 7
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?
“Blood pressure goes up toward the end of pregnancy.”
“My breathing will get deeper and a little faster.”
“I‘ll notice a decreased pigmentation in my skin.”
“There will be a curvature in the upper spine area.”
a.
b.
c.
d.
ANS: B
The pregnant woman breathes more deeply, and her respiratory rate may increase slightly.
DIF: Cognitive Level: Comprehension
REF: p. 57
TOP: Normal Physiological Changes in Pregnancy
OBJ: 7 | 13
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
woman‘s expected delivery date using Nägele‘s 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 if necessary.
DIF: Cognitive Level: Analysis
REF: p. 52 | Box 4.2
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: p. 54
OBJ: 3 | 6
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/minute from a rate of 160 beats/minute
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earlier in the pregnancy. What is the nurse‘s first action?
Ask if the patient has taken a sedative.
Notify the physician.
Turn the patient to her right side.
Record the rate as a normal finding.
a.
b.
c.
d.
ANS: D
The FHR at term ranges from a low of 110 to 120 beats/minute to a high of 150 to 160
beats/minute. This should be recorded as normal. The FHR drops in the late stages of
pregnancy.
DIF: Cognitive Level: Application
REF: p. 54
OBJ: 3
TOP: Assessing Fetal Heart Tone
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9. A woman‘s prepregnant weight is determined to be average for her height. What will the
nurse advise the woman regarding recommended weight gain during pregnancy?
10 to 20 pounds
15 to 25 pounds
25 to 35 pounds
28 to 40 pounds
a.
b.
c.
d.
ANS: C
The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35
pounds.
DIF: Cognitive Level: Knowledge
REF: p. 63
OBJ: 8
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 don‘t 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
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: p. 64
OBJ: 8 | 13
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?
Eat three well-balanced meals per day and limit snacks.
Drink a full glass of fluid at the beginning of each meal.
Have crackers handy at the bedside, and eat a few before getting out of bed.
Eat a bland diet and avoid concentrated sweets.
a.
b.
c.
d.
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: p. 70 | Table 4.6
OBJ: 10
TOP: Common Discomforts in Pregnancy
KEY: Nursing Process Step: Implementation
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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 nurse‘s initial action?
a. Assess food intake.
b. Weigh the patient again.
c. Take the blood pressure.
d. Notify the physician.
ANS: C
The marked weight gain may be an indication of pre-eclampsia. The blood pressure should be
assessed before notifying the physician.
DIF: Cognitive Level: Application
REF: p. 49
OBJ: 4
TOP: Pre-eclampsia
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–omega 3 fatty 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: p. 61
OBJ: 8
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
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: p. 65
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?
Amenorrhea
Uterine enlargement
HCG detected in the urine
Fetal heartbeat
a.
b.
c.
d.
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.
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DIF: Cognitive Level: Knowledge
REF: p. 54
OBJ: 6 | 7
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 baby‘s heartbeat?” At what
gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or
fetoscope?
a. 4 weeks
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: p. 54
OBJ: 7
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 nurse‘s best response?
“You may notice the baby moving around the 4th or 5th month.”
“Quickening varies with every woman.”
“You‘ll feel something by the end of the first trimester.”
“The baby will be big enough for you to feel in your 8th month.”
a.
b.
c.
d.
ANS: A
Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of
gestation.
DIF: Cognitive Level: Knowledge
REF: p. 53
OBJ: 7
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 mother‘s temperature and improves fetal circulation.
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
TOP: Exercise During Pregnancy
REF: p. 67
OBJ: 9 | 13
KEY: Nursing Process Step: Planning
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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 differ 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 nurse‘s advice.
ANS: A
The pregnant adolescent must cope with two of life‘s most stress-laden transitions
simultaneously: adolescence and parenthood.
DIF: Cognitive Level: Comprehension
REF: p. 65
TOP: Psychological Adaptations to Pregnancy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
OBJ: 12
20. At what age is a woman who becomes pregnant for the first time described as an “elderly
primip”?
After 25 years old
After 28 years old
After 30 years old
After 35 years old
a.
b.
c.
d.
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: p. 75
OBJ: 12
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?
Chadwick‘s
Hegar‘s
McDonald‘s
Goodell‘s
a.
b.
c.
d.
ANS: D
Goodell‘s sign is one of the probable signs of pregnancy and describes a softened cervix and
vagina.
DIF: Cognitive Level: Knowledge
REF: p. 53
OBJ: 1 | 6 | 7
TOP: Goodell‘s 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?
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a.
b.
c.
d.
Endovaginal ultrasound
Pap test
Complete blood count
Hemoglobin electrophoresis
ANS: D
Hemoglobin electrophoresis identifies the 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: p. 50 | Table 4.1
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 prenatal 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: p. 78
OBJ: 4
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 explain as the most likely cause of this symptom?
Supine hypotension syndrome
Gestational diabetes
Pregnancy-induced hypertension
Malnutrition
a.
b.
c.
d.
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: p. 57
OBJ: 7
TOP: Physiological Changes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
MULTIPLE RESPONSE
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1. 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: p. 69
OBJ: 10
TOP: Flight Precautions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. 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: p. 59
OBJ: 7
TOP: Joint Changes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. 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.)
Goes fishing every afternoon.
Has revised his financial plan.
Spends leisure time with his friends.
Traded his sports car for a sedan.
Helped select a crib.
a.
b.
c.
d.
e.
ANS: B, D, E
Active planning for an infant is an indication of the acceptance stage. Concentration on a
hobby and spending time away from home are indicators of nonacceptance.
DIF: Cognitive Level: Comprehension
REF: pp. 73-74
OBJ: 11
TOP: Stages of Fatherhood
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. What nursing interventions are appropriate for the prenatal patient in terms of prenatal care?
(Select all that apply.)
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a.
b.
c.
d.
e.
Offer nutritional counseling.
Reinforce responsibility of parenthood.
Reduce risk factors.
Improve health practices.
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: pp. 48-49
OBJ: 2 | 3
TOP: Goals of Prenatal Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. The nurse recognizes which behavior characteristic(s) of women in their first trimester of
pregnancy? (Select all that apply.)
Showing off her sonogram photos
Ambivalence about pregnancy
Emotional and labile mood
Focusing on her infant
Fatigue
a.
b.
c.
d.
e.
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: p. 73
OBJ: 11
TOP: Behaviors of First Trimester
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse reminds the prenatal patient that she should add
kcal to her daily intake
to nourish the fetus.
ANS:
300
The recommended dietary intake increase is 300 kcal a day.
DIF: Cognitive Level: Comprehension
REF: p. 64
OBJ: 8
TOP: Nutrition During Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 05: Nursing Care of Women with Complications During Pregnancy
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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?
Hyperemesis gravidarum usually lasts for the duration of the pregnancy.
Hyperemesis gravidarum causes dehydration and electrolyte imbalances.
Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum.
The woman with hyperemesis gravidarum will have persistent vomiting without
weight loss.
a.
b.
c.
d.
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: p. 90
OBJ: 3
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
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: pp. 90-92| Table 5.2 | Figure 5.2
OBJ: 3
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. “I‘m 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, “I‘m here if you need to talk.” The nurse listens and acknowledges the woman‘s grief.
DIF: Cognitive Level: Application
REF: p. 93, Communication Box
OBJ: 3
TOP: Dilation and Evacuation (D&E)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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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.”
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: p. 95
OBJ: 3
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?
Low-lying placenta
Marginal placenta previa
Partial placenta previa
Total placenta previa
a.
b.
c.
d.
ANS: D
A total placenta previa describes a condition in which the placenta completely covers the
cervical opening.
DIF: Cognitive Level: Comprehension
REF: pp. 96-98
OBJ: 3
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
Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio
placentae.
DIF: Cognitive Level: Knowledge
REF: pp. 98-99
OBJ: 3
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.
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DIF: Cognitive Level: Analysis
REF: p. 103
OBJ: 3
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.
DIF: Cognitive Level: Comprehension
REF: p. 104
OBJ: 3
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: p. 105
OBJ: 4
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?
Placental hormones increase the resistance of cells to insulin.
Insulin cells cannot meet the body‘s demands as the woman‘s weight increases.
There is a decreased production of insulin during pregnancy.
The speed of insulin breakdown is decreased during pregnancy.
a.
b.
c.
d.
ANS: A
Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.
DIF: Cognitive Level: Knowledge
REF: p. 105
OBJ: 4
TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
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?
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a.
b.
c.
d.
Insulin can cross the placental barrier to the fetus.
Insulin does not cross the placental barrier to the fetus.
Oral agents do not cross the placenta.
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: p. 107
OBJ: 4
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 mother‘s 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.
DIF: Cognitive Level: Comprehension
REF: p. 112
OBJ: 4
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: pp. 115-116 | Table 5.9
OBJ: 5
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
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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.
DIF: Cognitive Level: Knowledge
REF: p. 102
OBJ: 3
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?
Diarrhea
Urticaria
Blurred vision
Backache
a.
b.
c.
d.
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: p. 90, Patient Teaching Box
OBJ: 3
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?
Activity restriction
Balanced nutrition
Increased fluid intake to ensure adequate hydration
Instruction about the effect of diuretics
a.
b.
c.
d.
ANS: A
Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the
placenta and enhancing fetal oxygenation.
DIF: Cognitive Level: Application
REF: p. 102
OBJ: 3
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?
To prevent convulsions
To promote diaphoresis
To increase reflex irritability
To act as a saline cathartic
a.
b.
c.
d.
ANS: A
Magnesium sulfate is a central nervous system depressant given to prevent seizures.
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DIF: Cognitive Level: Knowledge
REF: p. 102
OBJ: 3
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 highest priority nursing intervention?
a. Count respirations and report a rate of less than 12 breaths/minute.
b. Count respirations and report a rate of more than 20 breaths/minute.
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: p. 102
OBJ: 3
TOP: Magnesium Sulfate
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?
Ergonovine maleate (Ergotrate)
Oxytocin
Calcium gluconate
Hydralazine (Apresoline)
a.
b.
c.
d.
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: p. 102
OBJ: 3
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: p. 98
OBJ: 3
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
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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: p. 111
OBJ: 4
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: p. 114
OBJ: 4
TOP: Pyelonephritis
KEY: Nursing Process Step: Data Collection
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-Fowler‘s 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: p. 98
OBJ: 3
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 won‘t seem so bad.”
d. “It will most likely resolve 6 weeks or so after the baby is born.”
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ANS: D
GDM usually resolves by 6 weeks after delivery.
DIF: Cognitive Level: Application
REF: p. 104
OBJ: 3
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: p. 86 | Table 5.1
OBJ: 2
TOP: Diagnostic Tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
26. The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will
the nurse assess for in the newborn?
Meconium ileus
Diarrhea
Hypoglycemia
Muscle tremors
a.
b.
c.
d.
ANS: C
The fetus responds to the hyperglycemia from the mother‘s blood and produces increased
insulin. This insulin may cause hypoglycemia in the infant after it is no longer exposed to the
mother‘s blood.
DIF: Cognitive Level: Application
REF: p. 105 | Box 5.4
OBJ: 4
TOP: Hypoglycemia in Macrosomic Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
1. The nurse educates prenatal patients about the threat of TORCH infections. Which infections
are included in this classification? (Select all that apply.)
Toxoplasmosis
Toxemia
Cytomegalovirus
Rubella
a.
b.
c.
d.
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e. Herpes simplex
ANS: A, C, D, E
The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.
DIF: Cognitive Level: Knowledge
REF: p. 111
OBJ: 5
TOP: TORCH Infections
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. 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
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: pp. 119-120 OBJ: 7
TOP: Impact of High-Risk Pregnancies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. 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.)
Privacy
An opportunity to hold the infant
Materials about support groups
A memento (footprint or lock of hair)
A warm beverage
a.
b.
c.
d.
e.
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: p. 120
OBJ: 7
TOP: Stillborn Infant
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4. 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.)
Citrus fruits enhance absorption of iron.
Bran products support iron deficiency.
Milk will disguise the taste of the iron.
The iron therapy will continue for about 3 months.
Tea should be avoided while taking iron.
a.
b.
c.
d.
e.
ANS: A, D, E
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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: p. 109
OBJ: 4
TOP: Iron Deficiency Anemia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
5. The nurse takes into consideration that the patient with placenta previa is at risk for
postpartum infection for what reasons? (Select all that apply.)
Vaginal organisms can invade the placenta.
The undernourished placenta becomes necrotic.
The amniotic fluid can become infected.
The placenta is an excellent growth medium.
The misplaced placenta weakens the uterine wall.
a.
b.
c.
d.
e.
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: p. 98
OBJ: 3
TOP: Infection with Placenta Previa
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. 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: p. 108
OBJ: 3
TOP: Obesity
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
7. 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.
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d. Communicate in a nonjudgmental 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 abuser outside the
home. 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: pp. 116-119 OBJ: 6
TOP: Battering
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Injury Prevention
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Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. What does the nurse note when measuring the frequency of a laboring woman‘s 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: p. 126
OBJ: 3
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: p. 127
OBJ: 3
TOP: Interval
KEY: Nursing Process Step: N/A
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: p. 127 | Safety Alert
OBJ: 4
TOP: Contraction/Fetal Compromise
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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4. Vaginal examination reveals the presenting part is the infant‘s head, which is well flexed on
the chest. What is this presentation?
Vertex
Military
Brow
Face
a.
b.
c.
d.
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: p. 129
OBJ: 3
TOP: Fetal Position
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: p. 143
OBJ: 4
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 fetus‘s hips
are flexed and the knees are extended. How would the nurse record this presentation?
Complete breech
Frank breech
Double footling
Buttocks presentation
a.
b.
c.
d.
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: pp. 128-129 | Figure 6.7
OBJ: 3 | 4
TOP: Components of the Birth Process
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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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?
Contractions that are relieved by walking
Discomfort in the abdomen and groin
A decrease in vaginal discharge
Regular contractions becoming more frequent and intense
a.
b.
c.
d.
ANS: D
In true labor, contractions gradually develop a regular pattern and become more frequent,
longer, and more intense.
DIF: Cognitive Level: Application
REF: p. 133
OBJ: 6
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 nurse‘s 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.
DIF: Cognitive Level: Application
REF: p. 133
OBJ: 5
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?
They get the infant positioned for delivery.
They push the infant into the vagina.
They dilate and efface the cervix.
They get the mother prepared for true labor.
a.
b.
c.
d.
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: p. 149 | Table 6.5
OBJ: 5
TOP: First Stage of Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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 woman‘s 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 becomes irritable, suspect that she has progressed to
the transition stage of labor.
DIF: Cognitive Level: Analysis
REF: p. 149 | Table 6.5
OBJ: 5
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 mother‘s body.
d. Separate the placenta from the uterine wall.
ANS: C
The contractions push the infant out of the mother‘s body as the second stage of labor ends
with the birth of the infant.
DIF: Cognitive Level: Knowledge
REF: p. 149 | Table 6.5
OBJ: 5
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.
DIF: Cognitive Level: Knowledge
REF: p. 149 | Table 6.5
OBJ: 5
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.
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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: p. 149 | Table 6.5
OBJ: 5
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?
Find the physician.
Stay with the woman and use the call bell to get help.
Send the woman‘s partner to locate a registered nurse.
Assist with deep breathing to slow the labor process.
a.
b.
c.
d.
ANS: B
If birth appears to be imminent, the nurse should not leave the woman and should summon
help with the call bell.
DIF: Cognitive Level: Application
REF: p. 134
OBJ: 5
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 well-oxygenated fetus
Compression of the umbilical cord
Compression of the fetal head
Uteroplacental insufficiency
a.
b.
c.
d.
ANS: A
Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.
DIF: Cognitive Level: Analysis
REF: p. 141
OBJ: 4
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.
DIF: Cognitive Level: Application
REF: p. 148
OBJ: 8
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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: p. 149 | Table 6.5
OBJ: 8
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?
Check the fundus for position and firmness.
Report to the doctor immediately.
Change the pads and chart the time.
Time how long it takes to soak one pad.
a.
b.
c.
d.
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: p. 153
OBJ: 8
TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process 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 nurse‘s initial action?
Stop the oxytocin infusion.
Increase the intravenous flow rate.
Reposition the woman on her side.
Start oxygen via nasal cannula.
a.
b.
c.
d.
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: p. 142
OBJ: 8
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.
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d. Change the perineal pad frequently.
ANS: A
An ice pack can be placed on the mother‘s 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: p. 153
OBJ: 8
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 newborn‘s Apgar score is 9. What does the nurse understand that
a score of 9 indicates?
The newborn will require resuscitation.
The newborn may have physical disabilities.
The newborn will have above average intelligence.
The newborn is in stable condition.
a.
b.
c.
d.
ANS: D
Apgar scoring is a system for evaluating the infant‘s 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: p. 158 | Table 6.6
OBJ: 9
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. A nursing student assisting a woman in labor asks the instructor, “What does it mean when the
baby is at minus 1 station?” After being given an explanation by the nursing instructor, what
statement by the student indicates an accurate understanding of station?
a. “Fetal head is above the ischial spines.”
b. “Fetal head is below the ischial spines.”
c. “Fetal head is engaged in the mother‘s 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 the ischial spines.
DIF: Cognitive Level: Comprehension
REF: p. 132 | Figure 6.10
OBJ: 5
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
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In the fourth stage of labor, a priority nursing action is identifying and preventing
hemorrhage.
DIF: Cognitive Level: Application
REF: p. 152
OBJ: 5 | 8
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
Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.
DIF: Cognitive Level: Application
REF: p. 136
OBJ: 6 | 7 | 8
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: p. 142
OBJ: 8
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 loss minimal and oxygen consumption low.
Hypothermia can cause cold stress, which leads to hypoxia.
DIF: Cognitive Level: Comprehension
REF: p. 154
OBJ: 9
TOP: Thermoregulation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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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: p. 149
OBJ: 7
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 nurse‘s priority
assessment immediately following this procedure?
Fetal heart rate
Fluid amount
Maternal blood pressure
Deep tendon reflexes
a.
b.
c.
d.
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: p. 143
OBJ: 8
TOP: Rupture of Membranes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
1. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity
through which interventions? (Select all that apply.)
Provide for extreme modesty.
Assign a male caregiver.
Arrange for the husband/partner to participate in labor.
Provide adequate pain control.
Respect protective amulets.
a.
b.
c.
d.
e.
ANS: A, D, E
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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: p. 124
OBJ: 2
TOP: Cultural Considerations
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. What are the advantages of a freestanding birth center? (Select all that apply.)
a. Homelike 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: p. 125
OBJ: 2
TOP: Free-Standing Birth Centers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. 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 decelerations indicate cord compression and early decelerations indicate head
compressions.
DIF: Cognitive Level: Comprehension
REF: p. 141
OBJ: 4 | 5
TOP: Late Decelerations
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. 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
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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: pp. 136-137 OBJ: 6 | 7
TOP: False Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
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Chapter 07: Nursing Management of Pain During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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 patient‘s expression of pain?
It reduces the patient‘s perception of pain.
It is intensified by the vertex position of the fetus.
It is influenced by culture.
It can be completely controlled by nonpharmacological techniques.
a.
b.
c.
d.
ANS: C
Culture influences how women feel about birth and what is an acceptable response to pain.
DIF: Cognitive Level: Comprehension
REF: p. 168
OBJ: 4
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: p. 167
OBJ: 1 | 4
TOP: Endorphins KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. A nurse instructs a woman‘s 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: p. 169 | Box 7.1
OBJ: 6
TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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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?
Use slow-paced breathing.
Hold her breath and push.
Blow in short breaths.
Use rapid-paced breathing.
a.
b.
c.
d.
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: p. 170
OBJ: 3 | 6
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: p. 170 | Box 7.2
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: p. 171 | Box 7.2
OBJ: 4
TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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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: p. 172
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?
Offer warm liquids to the patient.
Encourage the patient to pant.
Engage the patient in conversation.
Assist the patient to the knee-chest position.
a.
b.
c.
d.
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: p. 170
OBJ: 3 | 4
TOP: Panting
KEY: Nursing Process Step: Implementation
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: p. 173 | Table 7.2
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
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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: p. 173
OBJ: 8
TOP: Epidural Block
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
woman‘s ability to have an urge to void. The patient may have to be catheterized.
DIF: Cognitive Level: Knowledge
REF: pp. 173-174, Safety Alert Box
OBJ: 8
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: p. 173
OBJ: 7 | 8
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: p. 175
OBJ: 7 | 8
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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?
“I‘m having a contraction. Can I get the pudendal block now?”
“I‘ll get the pudendal block right before I deliver.”
“The nurse-midwife will insert the needles into my vagina.”
“It takes a few minutes after the medicine is administered to make me feel numb.”
a.
b.
c.
d.
ANS: A
The pudendal block does not block pain from contractions and is given just before birth.
DIF: Cognitive Level: Comprehension
REF: p. 176
OBJ: 7 | 8
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 can‘t 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: p. 177, Nursing Care Plan 7.1
OBJ: 4
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 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: p. 166
OBJ: 6
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?
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a.
b.
c.
d.
Abnormal clotting
Previous cesarean delivery
History of migraine headaches
History of diabetes mellitus
ANS: A
An epidural block is not used if a woman has abnormal blood clotting.
DIF: Cognitive Level: Comprehension
REF: p. 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?
Increased use of oxygen
Cervical laceration
Uterine rupture
Compression of the cord
a.
b.
c.
d.
ANS: B
Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.
DIF: Cognitive Level: Comprehension
REF: p. 170
OBJ: 4
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: p. 168
OBJ: 5
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 patient‘s 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: p. 170
OBJ: 3
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: p. 166
OBJ: 1
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: p. 171
OBJ: 4 | 6 | 8
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 nurse‘s best response to explain the frequent blood pressure assessments?
They ensure that unsafe levels of hypertension do not occur.
They help assess for the need for further pain relief.
They monitor the progress of labor.
They ensure adequate placental perfusion.
a.
b.
c.
d.
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: p. 173
OBJ: 7 | 8
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
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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-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: p. 166
OBJ: 5 | 6
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?
Urinary retention
Severe lower back pain
A shorter labor process
Nausea
a.
b.
c.
d.
ANS: B
If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the
mother‘s sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is
often longer with this fetal position.
DIF: Cognitive Level: Application
REF: p. 168
OBJ: 4
TOP: Maternal Condition
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. What typical types of classes are available to help expectant parents prepare for parenthood?
(Select all that apply.)
Infant care
Breastfeeding
Gestational diabetes
Sources of financial aid
Yoga
a.
b.
c.
d.
e.
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: p. 164
OBJ: 2
TOP: Prenatal Classes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
2. 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.)
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a.
b.
c.
d.
e.
First-stage breathing
Abdominal breathing
Fourth-stage breathing
Modified paced breathing
Patterned paced breathing
ANS: A, B, D, E
First-stage breathing includes the techniques of modified paced 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 woman‘s recovery stage and does not require a breathing technique.
DIF: Cognitive Level: Comprehension
REF: p. 170
OBJ: 3 | 5
TOP: Breathing Exercises
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. 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: p. 166
OBJ: 3 | 4
TOP: Childbirth Pain
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. 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.
DIF: Cognitive Level: Knowledge
REF: pp. 168-169 OBJ: 6
TOP: Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. 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
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b.
c.
d.
e.
Pelvic rock
Tailor sitting
Sit-ups
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 intra-abdominal pressure.
DIF: Cognitive Level: Comprehension
REF: p. 165
OBJ: 6
TOP: Helpful Exercises
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. 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.
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: p. 168
OBJ: 5 | 6
TOP: Advantages of Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. 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 assess 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: p. 173
OBJ: 8
TOP: Epidural Anesthesia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
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8. 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: p. 172 | Table 7.1
OBJ: 8
TOP: Narcotic Analgesia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
Chapter 08: Nursing Care of Women with Complications During Labor and Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/minute.
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: p. 186
TOP: Obstetric Procedures—Amniotomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2.
OBJ: 3
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 nurse‘s 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 compromise or excessive uterine contractions occur.
DIF: Cognitive Level: Application
REF: p. 186
TOP: Obstetric Procedures—Induction of Labor
KEY: Nursing Process Step: Implementation
OBJ: 3
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MSC: NCLEX: Physiological Integrity
3. What nursing care should be provided to a woman with a third-degree laceration immediately
after delivery?
Warm compresses to the perineum
Cold pack to the perineum
Warm sitz bath
Elevation of hips to prevent edema
a.
b.
c.
d.
ANS: B
Ice is applied to the perineum to reduce bruising and edema.
DIF: Cognitive Level: Application
REF: p. 188
OBJ: 3
TOP: Obstetric Procedures—Lacerations
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 woman‘s 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 contractions diminish after the active phase.
DIF: Cognitive Level: Comprehension
REF: p. 196 | Table 8.2
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
TOP: Abnormal Labor
MSC: NCLEX: Physiological Integrity
REF: p. 196
OBJ: 2 | 5
KEY: Nursing Process Step: Implementation
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
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b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation
ANS: C
Pressure from forceps may injure the infant‘s facial nerve, which is evidenced by facial
asymmetry.
DIF: Cognitive Level: Application
REF: p. 190
OBJ: 3
TOP: Obstetric Procedures—Forceps 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 infant‘s 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: p. 190
OBJ: 2
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 won‘t 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
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 College of Obstetricians and Gynecologists
(ACOG).
DIF: Cognitive Level: Comprehension
REF: p. 184 | Table 8.1
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
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c. Standing with support
d. Sitting up and leaning forward on the overbed 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: p. 199
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 contractions.
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: p. 201
OBJ: 3 | 5
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: p. 201
OBJ: 3 | 6
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?
Maternal tachycardia
Maternal hypertension
Fetal bradycardia
Fetal hypokalemia
a.
b.
c.
d.
ANS: A
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Maternal tachycardia is the common negative side effect of terbutaline, which should be
corrected with a dose of propranolol.
DIF: Cognitive Level: Comprehension
REF: p. 203
OBJ: 6 | 7 | 8
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: p. 202
OBJ: 7
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 from the side of the 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: p. 194
OBJ: 4
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‘s (head down) position displaces the fetus upward to stop compression of
the prolapsed cord.
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DIF: Cognitive Level: Application
REF: p. 205
OBJ: 8
TOP: Emergencies During Childbirth—Prolapsed 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?
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: p. 203
OBJ: 8
TOP: Cesarean Section
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17. A pregnant woman‘s 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‘s 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: p. 186
OBJ: 6
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 placed on an intravenous 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
TOP: Preterm Labor
MSC: NCLEX: Physiological Integrity
REF: p. 203
OBJ: 6
KEY: Nursing Process Step: Implementation
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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 woman‘s 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: p. 200
OBJ: 5
TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance
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?
Give the pain remedy.
Notify the charge nurse immediately.
Turn the patient to her back and flex her knees.
Suggest that the coach give her a back rub.
a.
b.
c.
d.
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: p. 206
OBJ: 3
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: p. 185
OBJ: 3
TOP: Cervical Ripening
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22. The nurse is caring for a patient who is threatening preterm labor and has been given
glucocorticoids. What is the purpose of glucocorticoid administration?
Prevent infection.
Increase fetal lung maturity.
Increase blood flow from placenta.
Relax the cervix.
a.
b.
c.
d.
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ANS: B
Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.
DIF: Cognitive Level: Comprehension
REF: p. 203
OBJ: 6
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?
18-year-old primigravida with a fetal breech presentation
25-year-old multigravida with history of previous cesarean section
35-year-old multigravida with history of precipitate birth
16-year-old primigravida with a twin pregnancy
a.
b.
c.
d.
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 woman‘s 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: p. 201
OBJ: 7
TOP: Precipitate Birth
KEY: Nursing Process Step: Implementation
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?
Elevated uterine resting tone
Painful and poorly coordinated contractions
Implementation of fluid restriction
Use of frequent position changes
a.
b.
c.
d.
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: p. 196
OBJ: 5 | 6
TOP: Hypotonic Labor Dysfunction
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. What sign(s) of infection should the nurse assess for after an amniotomy?
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
ANS: B
Increase in the FHR above 160 beats/minute frequently precedes a woman‘s temperature
elevation. All the other options are normal findings for late pregnancy.
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DIF: Cognitive Level: Application
REF: p. 186
OBJ: 3
TOP: Postamniotomy Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
1. 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: pp. 183-184 OBJ: 2
TOP: Rationales for Labor Induction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. 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 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: p. 184
OBJ: 3
TOP: Hypotonic Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. 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
TOP: Complication of Oxytocin
REF: p. 186
OBJ: 6
KEY: Nursing Process Step: Planning
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. 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.)
Place a warm, moist washcloth over the breast.
Brush the nipples with a dry washcloth.
Gently pull on the nipples.
Apply suction to the nipples with a breast pump.
Press the palms of her hands down on her breasts.
a.
b.
c.
d.
e.
ANS: B, C, D
Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction to nipples
with a breast pump are all effective methods of nipple stimulation, which will increase the
quality of uterine contractions.
DIF: Cognitive Level: Application
REF: p. 184
OBJ: 5
TOP: Nipple Stimulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. 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: p. 184
OBJ: 2
TOP: Induction
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. 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.
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.
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DIF: Cognitive Level: Application
REF: pp. 184-185 OBJ: 3
TOP: Cervical Ripening
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
Chapter 09: The Family After Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is assessing a newborn. Which sign would indicate hypoglycemia?
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: p. 231
OBJ: 9
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: p. 211
OBJ: 2
TOP: Fundus Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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: p. 240
OBJ: 14
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TOP: Breastfeeding—Supplemental Feedings
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. After delivery, the nurse‘s assessment reveals a soft, boggy uterus located above the level of
the umbilicus. What is the most appropriate nursing intervention?
Notify the physician.
Massage the fundus.
Initiate measures that encourage voiding.
Position the patient flat.
a.
b.
c.
d.
ANS: B
A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
DIF: Cognitive Level: Application
REF: p. 214
OBJ: 9
TOP: Boggy Uterus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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: p. 214
OBJ: 4
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?
Lochia should disappear 2 to 4 weeks postpartum.
It is normal for the lochia to have a slightly foul odor.
A change in lochia from pink to bright red should be reported.
A decrease in flow will be noticed with ambulation and activity.
a.
b.
c.
d.
ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be
reported.
DIF: Cognitive Level: Application
REF: pp. 214-215 OBJ: 19
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 day.
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.
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ANS: B
Cleansing from front to back prevents contamination from the rectal area.
DIF: Cognitive Level: Application
REF: p. 216
OBJ: 2
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: p. 220
OBJ: 2
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.”
d. “I put only the nipple in the baby‘s 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: p. 236| Table 9.4
OBJ: 10
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?
Consume 500 more calories than her usual prepregnancy diet.
Eat less meat and more fruits and vegetables.
Drink 3 to 4 tall glasses of fluid daily.
Eat 1000 more calories than her usual prepregnancy diet.
a.
b.
c.
d.
ANS: A
To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each
day over her prepregnancy diet.
DIF: Cognitive Level: Comprehension
TOP: Breastfeeding—Maternal Nutrition
REF: p. 242
OBJ: 18
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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 woman will not ovulate in the absence of menstrual flow.
Most nonlactating women resume menstruation about 2 months postpartum.
Generally, a woman does not ovulate in the first few cycles after childbirth.
The return of menstruation is delayed when a woman does not breastfeed.
a.
b.
c.
d.
ANS: B
Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
DIF: Cognitive Level: Comprehension
REF: p. 217
OBJ: 4
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: p. 220
OBJ: 2
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
ANS: C
Newborns lose heat quickly after birth as fluid evaporates from their bodies.
DIF: Cognitive Level: Comprehension
REF: p. 227 | Table 9.3
OBJ: 2
TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. What will the nurse‘s instructions for a new mother to care for the infant‘s umbilical cord
include?
Keeping the area covered with a sterile dressing
Dressing the stump with antibiotic ointment at every diaper change
Fastening the diaper low to allow for air circulation
Giving the newborn a daily tub bath until the cord falls off
a.
b.
c.
d.
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ANS: C
Diaper placement below the umbilical stump allows for drying by air circulation.
DIF: Cognitive Level: Application
REF: p. 230
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?
Wear a well-fitting bra continuously for several days.
Stand in a warm shower, letting the water spray over the breasts.
Express small amounts of milk from the breasts several times a day.
Massage the breasts when they ache.
a.
b.
c.
d.
ANS: A
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: pp. 241-242 OBJ: 14 | 19
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 don‘t 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: p. 226
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?
“I‘ll get you some aspirin to relieve the cramping that you feel.”
“Afterpains are more intense with your first baby.”
“Breastfeeding releases a hormone that causes your uterus to contract.”
“A change of position when you‘re breastfeeding might help.”
a.
b.
c.
d.
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: p. 235
OBJ: 2
TOP: Afterpains with Breastfeeding
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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?
Positioning the bottle so that the nipple is full of formula during the entire feeding
Heating the infant formula in a microwave
Burping the infant after 4 ounces and again when the bottle is empty
Propping a bottle for a feeding
a.
b.
c.
d.
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: p. 244 | Skill 9.7
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 woman‘s 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.
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: p. 220
OBJ: 5
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?
“I can thaw frozen breast milk in the microwave.”
“I‘ll put enough breast milk for one day in a container.”
“Breast milk can be stored in glass containers.”
“Breast milk can be kept in the refrigerator for up to 3 months.”
a.
b.
c.
d.
ANS: C
Breast milk can be safely stored in glass or clear hard plastic containers.
DIF: Cognitive Level: Comprehension
REF: p. 241
OBJ: 14
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?
Ask, “Is this your band number?”
Confirm room number of mother.
Ask the mother to identify herself verbally.
Check the band number of the infant with that of the mother.
a.
b.
c.
d.
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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: p. 228
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: p. 231
OBJ: 8
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.”
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: p. 211
OBJ: 3
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 nurse‘s most appropriate action?
a. Contact the hospital chaplain.
b. Request the couple‘s clergy.
c. Baptize the newborn.
d. Ask the physician to baptize the newborn.
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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 infant‘s 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 patient‘s immediate health needs.
DIF: Cognitive Level: Application
REF: p. 225
OBJ: 7
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?
“Consider formula feeding for the first few days.”
“Pumping breast milk would be best for now.”
“Take pain medication 30 to 40 minutes prior to nursing.”
“Use the football hold when breastfeeding.”
a.
b.
c.
d.
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: p. 236
OBJ: 13
TOP: Breastfeeding
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. Which assessments would lead the nurse to determine the gestational age of the infant as
preterm? (Select all that apply.)
Thin, transparent skin
Vernix only in the body creases
Folded ear springs back slowly
Breast tissue under the nipple
Creases over entire sole
a.
b.
c.
d.
e.
ANS: A, C
The only signs of preterm are the thin skin and the slowly responding ear.
DIF: Cognitive Level: Application
REF: p. 229
OBJ: 2
TOP: Gestational Age Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. 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.
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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: p. 222
OBJ: 5
TOP: Postpartum Shower
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. What postpartum exercises should the nurse teach a patient who had a vaginal delivery
yesterday? (Select all that apply.)
Abdominal tighteners
Head lift
Pelvic tilt
Kegel exercises
Leg lifts
a.
b.
c.
d.
e.
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: p. 220
OBJ: 19
TOP: Postpartum Exercises
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. While instructing a new mother on formula preparations, the nurse would include what types?
(Select all that apply.)
Ready-to-feed formula
Concentrated liquid formula
Powdered formula
Cow‘s milk
Canned evaporated milk
a.
b.
c.
d.
e.
ANS: A, B, C
Formula choices are ready-to-use, concentrated liquid formula that will be diluted according
to the infant‘s needs, and powdered formula that is mixed as needed. Cow‘s milk and canned
evaporated milk are unsuitable, because they are nutritionally inadequate and stress the
kidneys.
DIF: Cognitive Level: Comprehension
REF: p. 243
OBJ: 17
TOP: Formula Choices
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. 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.)
Omit newborn‘s favorite feeding first.
Eliminate one feeding at a time.
Expect the need for comfort feeding.
Formula will need to be provided to substitute for feeding.
a.
b.
c.
d.
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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: p. 242
OBJ: 16
TOP: Weaning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
Chapter 10: Nursing Care of Women with Complications After Birth
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: p. 251 | Safety Alert
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: p. 253
OBJ: 2
TOP: Atony
KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What should the nurse‘s 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.
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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: p. 254
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 nurse‘s 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: p. 254
OBJ: 6
TOP: Bladder Distention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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?
Ritodrine
Magnesium sulfate
Oxytocin
Bromocriptine
a.
b.
c.
d.
ANS: C
Oxytocin (Pitocin) is the most common drug ordered to control uterine atony.
DIF: Cognitive Level: Comprehension
REF: p. 254
OBJ: 5
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 nurse‘s 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
TOP: Mastitis and Breastfeeding
MSC: NCLEX: Physiological Integrity
REF: pp. 258-259 OBJ: 6
KEY: Nursing Process Step: Implementation
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7. A woman had a vaginal delivery two days ago and is preparing for discharge. What will the
nurse plan to teach the woman to report to help prevent postpartum complications?
Fever
Change in lochia from red to white
Contractions
Fatigue and irritability
a.
b.
c.
d.
ANS: A
Increased temperature is a sign of infection. The other choices are normal in the postpartum
period.
DIF: Cognitive Level: Application
REF: p. 256
OBJ: 4
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: p. 256
OBJ: 2
TOP: Phlebitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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: p. 255
OBJ: 2
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
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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: p. 256
OBJ: 5
TOP: Anticoagulant Therapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
11. What statement by the patient leads the nurse to determine a woman with mastitis understands
treatment instructions?
“I will apply cold compresses to the painful areas.”
“I will take a warm shower before nursing the baby.”
“I will nurse first on the affected side.”
“I will empty the affected breast every 8 hours.”
a.
b.
c.
d.
ANS: B
Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.
DIF: Cognitive Level: Comprehension
REF: p. 259
OBJ: 6
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. “I‘ll bet you will snap out of this funk real soon.”
c. “Why don‘t you arrange for a babysitter so you and your husband can have a night
out?”
d. “Let‘s 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: pp. 259-260 OBJ: 6 | 7
TOP: Depression
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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
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Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus
formation in the postpartum woman.
DIF: Cognitive Level: Application
REF: p. 257
OBJ: 4
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: p. 257 | Table 10.2
OBJ: 2
TOP: Puerperal Infections
KEY: Nursing Process Step: Data Collection
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 woman‘s 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: pp. 259-260 OBJ: 7
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 can‘t believe how different my life is from what I expected.”
What is the best nursing response to the woman‘s 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 mother‘s feelings about motherhood and her infant.
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DIF: Cognitive Level: Application
REF: pp. 259-260 OBJ: 6 | 7
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?
Cervical laceration
Hematoma
Endometritis
Retained placental fragments
a.
b.
c.
d.
ANS: B
Delivering a large infant and a prolonged labor are risk factors for hematoma formation.
DIF: Cognitive Level: Analysis
REF: p. 255
OBJ: 3
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
TOP: Subinvolution of the Uterus
MSC: NCLEX: Physiological Integrity
REF: p. 255
OBJ: 2
KEY: Nursing Process Step: Implementation
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: p. 256
OBJ: 2 | 6
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?
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a.
b.
c.
d.
Concerned and reports a probable cervical laceration
Attentive and massages the uterus to expel retained clots
Distressed and reports a possible clotting disorder
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: p. 255
OBJ: 2 | 6
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 patient‘s leg is flexed and foot sharply
dorsiflexed. Where does the patient report that the pain is felt?
Groin
Achilles tendon
Top of the foot
Calf of the leg
a.
b.
c.
d.
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: p. 256
OBJ: 2
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: p. 257
OBJ: 6
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.
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DIF: Cognitive Level: Comprehension
REF: p. 250
OBJ: 3
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: p. 256|Safety Alert
OBJ: 5
TOP: Warfarin
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
1. 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.)
Hypertension
Blood clotting disorders
Anemia
Infection
Postpartum hemorrhage
a.
b.
c.
d.
e.
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: p. 250
OBJ: 3
TOP: Postpartum Shock
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. 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.
DIF: Cognitive Level: Analysis
REF: p. 253
OBJ: 4
TOP: Cessation of Lochia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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3. The nurse instructs the postpartum patient that her nutritional intake should include which
food(s) particularly supportive to healing? (Select all that apply.)
Legumes
Potatoes and pasta
Citrus fruits
Rice
Cantaloupe
a.
b.
c.
d.
e.
ANS: A, C, E
Legumes and foods containing vitamin C are conducive to healing. Starches are not.
DIF: Cognitive Level: Comprehension
REF: p. 258
OBJ: 4
TOP: Foods Conducive to Healing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. 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 the risk of mastitis and milk accumulation in the breast.
DIF: Cognitive Level: Comprehension
REF: p. 259
OBJ: 4
TOP: Reduction of the Risk of Mastitis
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. 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: p. 258 | Table 10.2
OBJ: 4
TOP: Urinary Tract Infection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse
anticipate? (Select all that apply.)
a. Provision of IV fluids
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b.
c.
d.
e.
Placement of an indwelling Foley catheter
Assessment of oxygen saturation
Administration of anticoagulants
Blood transfusion
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: p. 251
OBJ: 5
TOP: Hypovolemic Shock
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
COMPLETION
1. 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: p. 251
OBJ: 2
TOP: Weighing Perineal Pad
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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Chapter 11: The Nurse’s Role in Women’s Health Care
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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. A breast examination is a
focused assessment, not a test. A breast self-examination is important, but not a screening test.
A breast biopsy is a diagnostic test versus a test performed for basic screening purposes.
DIF: Cognitive Level: Comprehension
REF: p. 264
OBJ: 2
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: p. 264
OBJ: 2
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?
Makes cervical mucus hostile to sperm
Prevents ovulation
Prohibits implantation of the egg
Acts as a barrier by destroying sperm
a.
b.
c.
d.
ANS: B
Oral contraceptives contain a combination of estrogen and progesterone that suppresses
ovulation.
DIF: Cognitive Level: Comprehension
REF: p. 275
OBJ: 5
TOP: Oral Contraceptives
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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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: p. 277
OBJ: 5
TOP: IUDs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. What information will the nurse provide when educating a woman about the correct use of a
diaphragm?
Use of a spermicidal cream or jelly is not recommended.
Leave in place for at least 6 hours after intercourse.
Remove immediately after intercourse for douching.
It is effective for up to 48 hours if positioned properly.
a.
b.
c.
d.
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, but no more than 24 hours.
DIF: Cognitive Level: Comprehension
REF: p. 278
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: p. 275
OBJ: 5
TOP: Abstinence
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7. On day 13 of a 28-day cycle, a woman‘s 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: p. 274
OBJ: 6
TOP: Ovulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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?
Cloudy and tacky
Scant and thick
Thin and white
Clear and slippery
a.
b.
c.
d.
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: p. 274
OBJ: 6
TOP: Ovulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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: p. 274
OBJ: 6
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?
Drink tea or hot chocolate before going to bed.
Take a daily folic acid and vitamin C supplement.
Include complex carbohydrates and fiber in the diet.
Avoid exercise when symptoms occur.
a.
b.
c.
d.
ANS: C
A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic
disorder.
DIF: Cognitive Level: Application
REF: p. 268
OBJ: 3
TOP: Premenstrual Dysmorphic Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. 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?
Take a vitamin E supplement daily.
Do isometric exercises that can be practiced every day.
Include more dairy products and green, leafy vegetables in her diet.
Try to limit her intake of caffeine.
a.
b.
c.
d.
ANS: C
Foods rich in calcium include milk, dairy products, and green, leafy vegetables.
DIF: Cognitive Level: Application
REF: p. 285
OBJ: 7 | 8
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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12. 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?
Her periods have stopped for 1 year.
Her periods have been irregular and light for 12 months.
She has symptoms of vasomotor instability.
She experiences symptoms of decreased estrogen, such as dyspareunia.
a.
b.
c.
d.
ANS: A
When a woman‘s menstrual periods have stopped for 1 year, she is considered menopausal.
DIF: Cognitive Level: Comprehension
REF: pp. 285-286 OBJ: 7 | 8
TOP: Menopause KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. The nurse is planning to teach a woman about perimenopause. What would the nurse include
regarding lowered estrogen level?
a. It prevents 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: p. 284
OBJ: 7
TOP: Menopause KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. 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: p. 286
OBJ: 8
TOP: HRT
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15. What will the nurse advise when a woman asks what she can do to reduce the discomfort of
hot flashes?
“Aerobic exercise helps control hot flashes.”
“Increase the amount of calcium and vitamin D in your diet.”
“Dress in layers of cotton clothing.”
“Drink plenty of fluids, particularly caffeinated beverages.”
a.
b.
c.
d.
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: p. 285 | NCP 11.1
OBJ: 8
TOP: Prevention of Hot Flashes
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16. Which statement made by the nurse would teach an adolescent using tampons how to prevent
toxic shock syndrome (TSS)?
Super-absorbency tampons are effective for overnight absorption.
Tampons should be changed at least every 4 hours.
Gloves should be worn when changing tampons.
TSS can be prevented by using a pad for the first 2 days of menstrual flow.
a.
b.
c.
d.
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: p. 269
OBJ: 4
TOP: TSS
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. 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. “I‘ll 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: p. 282
OBJ: 5
TOP: Vasectomy
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. At her 6-week postpartum checkup, a woman states, “I am wondering about birth control. I
used oral contraceptives before, and I‘m breastfeeding now. Can I use the pill again?” What is
the nurse‘s best response?
a. “You should know that oral contraceptives increase your milk production.”
b. “Oral contraceptives can be taken once lactation is well established.”
c. “You don‘t 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: p. 276
OBJ: 5
TOP: Oral Contraceptives
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal
infection. 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
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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: p. 271 | Table 11.1
OBJ: 4
TOP: Candidiasis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. The nurse is providing an informational session on oral contraceptives. Which of the
following decrease effectiveness of oral contraceptives?
Antihistamines for seasonal allergies
Iron preparations for treatment of anemia
Appetite suppressants for weight reduction
Anticonvulsants for treatment of epilepsy
a.
b.
c.
d.
ANS: D
Anticonvulsants decrease the effectiveness of oral contraceptives.
DIF: Cognitive Level: Comprehension
REF: p. 276
OBJ: 5
TOP: Oral Contraceptives
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
21. The nurse is instructing a man considering a vasectomy. What instruction will the nurse
provide to address the postoperative time period?
Intercourse should be delayed for 6 weeks.
Sperm will still be ejaculated for a month.
Erections will be difficult to maintain.
Monthly sperm counts for a year will be necessary.
a.
b.
c.
d.
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: p. 282
OBJ: 5
TOP: Vasectomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22. 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
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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: p. 283
OBJ: 1
TOP: Dyspareunia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23. The nurse is educating a woman diagnosed with premenstrual dysphoric disorder (PMDD).
What is the best type of diet for the nurse to recommend?
High protein, low fat
High carbohydrate, high fiber
Low calorie, low fat
Low carbohydrate, high protein
a.
b.
c.
d.
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: p. 268
OBJ: 3
TOP: PMDD
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The nurse instructs a woman taking oral contraceptives to report which possible side effects?
(Select all that apply.)
Abdominal pain
Weight gain
Headache
Eye or visual problems
Speech disturbances
a.
b.
c.
d.
e.
ANS: A, C, D, E
The memory aid ACHES is helpful: abdominal pain, chest pain, headaches, eye problems, and
speech disturbances. Weight gain is an expected side effect of oral contraceptives.
DIF: Cognitive Level: Comprehension
REF: p. 276
OBJ: 5
TOP: Oral Contraceptives
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
2. The nurse cautions that women with a history of which disorders are not candidates for HRT?
(Select all that apply.)
Melanoma
Estrogen-dependent breast cancer
Hepatitis C
Thromboembolic disease
Hyperthyroidism
a.
b.
c.
d.
e.
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: p. 284
OBJ: 9
TOP: HRT
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
3. A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What
information will the nurse provide when educating this patient on alendronate (Fosamax)?
(Select all that apply.)
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: p. 285
OBJ: 2 | 8
TOP: Osteoporosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
Chapter 12: The Term Newborn
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. While inspecting a newborn‘s 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: p. 291
OBJ: 1
TOP: Newborn Assessment—Head
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What is the nurse‘s best response to a mother who is voicing concern about the molding of her
2- day-old infant?
a. “Molding doesn‘t cause any problems. Don‘t worry about it.”
b. “Did you deliver vaginally or by cesarean section?”
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c. “The baby‘s head conformed to the shape of the birth canal. It will go away soon.”
d. “A traumatic delivery can cause molding.”
ANS: C
The newborn‘s 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.
DIF: Cognitive Level: Application
REF: p. 291
OBJ: 1
TOP: Newborn Assessment—Head
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: p. 298
OBJ: 3
TOP: Newborn Assessment—Respiratory
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. When the newborn‘s 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 infant‘s 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.
DIF: Cognitive Level: Analysis
REF: p. 290 | Figure 12.3
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
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The rooting reflex causes the infant‘s head to turn in the direction of anything that touches the
cheek in anticipation of food.
DIF: Cognitive Level: Application
REF: p. 308
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?
Depressed and sunken
Triangular shaped
Smaller than the posterior fontanelle
Open and diamond shaped
a.
b.
c.
d.
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 closes between 12 and 18 months
of age.
DIF: Cognitive Level: Comprehension REF: p. 291
OBJ: 3
TOP: Newborn Assessment—Head
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. “I‘ll 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 baby‘s skin soft.”
c. “I should shampoo the head after washing the rest of the body.”
d. “I‘ll 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: pp. 305-306 |Skill 12.5
OBJ: 8
TOP: Home Care—Bathing 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 calm, full-term newborn. Which finding is
abnormal?
An axillary temperature of 36.6°C (98°F)
An apical pulse rate of 178 beats/minute
Respirations of 35 breaths/minute
Blood pressure of 80/50 mm Hg
a.
b.
c.
d.
ANS: B
The normal range for a newborn‘s pulse rate is 110 to 160 beats/minute. A pulse rate outside
of this range should be reported.
DIF: Cognitive Level: Comprehension
REF: p. 298
TOP: Newborn Assessment—Vital Signs
KEY: Nursing Process Step: Data Collection
OBJ: 3
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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?
Yellow
Brown
Greenish brown
Black and tarry
a.
b.
c.
d.
ANS: A
The stool of a breastfed infant is bright yellow, soft, and pasty.
DIF: Cognitive Level: Application
REF: p. 307
OBJ: 8
TOP: Newborn Assessment—Gastrointestinal 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. I‘ve
noticed she strains when she has a bowel movement.” What is nurse‘s most helpful response?
“Give the baby one serving of fruit per day.”
“Increase the amount and frequency of her feedings.”
“It sounds like the baby is uncomfortable because she is constipated.”
“Newborns might strain with bowel movements because their muscles aren‘t fully
developed.”
a.
b.
c.
d.
ANS: D
Straining in the newborn period is normal. It results from underdeveloped abdominal
musculature. No treatment is required.
DIF: Cognitive Level: Application
REF: p. 307
OBJ: 8
TOP: Newborn Assessment—Gastrointestinal 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: p. 300
OBJ: 3
TOP: Newborn Assessment—Weight
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. The parents of a newborn girl express concern about the infant‘s 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
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c. The increased amount of circulating blood from the mother throughout pregnancy
d. Trauma to the genitalia during the birth process
ANS: B
Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the
mother at birth.
DIF: Cognitive Level: Comprehension
REF: p. 302
OBJ: 8
TOP: Newborn Assessment—Genitourinary
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: p. 295
OBJ: 8
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?
Infant refuses a feeding.
Infant has an axillary temperature of 97°F.
Infant has three pasty, yellow-brown stools in 24 hours.
Infant‘s diaper is not wet after 8 hours.
a.
b.
c.
d.
ANS: D
Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse
practitioner to prevent dehydration.
DIF: Cognitive Level: Comprehension
REF: p. 300
OBJ: 8
TOP: Discharge Planning
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. A mother asks the nurse, “Do you think my baby recognized my voice?” The nurse should
consider which correct information when responding?
Voice recognition is delayed because the ears are not well developed at birth.
Infants respond to voice by increasing movements and sucking.
Infants initially respond to low-pitched voices.
Neonates can distinguish a mother‘s voice from other sounds in the first days of
life.
a.
b.
c.
d.
ANS: D
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The ability to discriminate between a mother‘s voice and other voices may occur as early as in
the first 3 days of life.
DIF: Cognitive Level: Knowledge
REF: p. 294
OBJ: 3 | 8
TOP: Newborn Assessment—Hearing
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?
Do nothing because this is a normal occurrence.
Report the discrepancy to the pediatrician immediately.
Decrease the interval between the infant‘s feedings.
Try feeding the infant a different type of formula.
a.
b.
c.
d.
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: p. 300
OBJ: 3
TOP: Newborn Assessment—Weight
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
nurse‘s most helpful response when instructing the parents?
Contact a pediatric dermatologist for topical medication.
Squeeze out the white material after cleansing the face.
Wash the infant‘s face with a mild astringent several times a day.
Leave the milia alone; it will disappear spontaneously. No treatment is needed.
a.
b.
c.
d.
ANS: D
Milia require no treatment. This skin manifestation will disappear spontaneously.
DIF: Cognitive Level: Application
REF: p. 302
OBJ: 5
TOP: Newborn Assessment—Skin
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 newborn‘s nose and mouth.
What is the nurse‘s first action?
Place the tip in the nose and squeeze the bulb gently.
Suction secretions from the nose before the mouth.
Depress the bulb before inserting the syringe tip into the mouth.
Insert the tip into the back of the mouth to reach mucus.
a.
b.
c.
d.
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: p. 297| Skill 12.2
OBJ: 3
TOP: Newborn Assessment—Respiratory
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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19. The mother of a 4-day-old calls the pediatrician‘s office because she is concerned about her
infant‘s skin. Which finding needs to be reported promptly to the child‘s pediatrician?
The hands and feet feel cooler than the rest of the body.
Skin is peeling on several parts of the infant‘s body.
There is a small pink patch on the left eyelid and one on the neck.
Today, the infant‘s skin has a yellowish tinge.
a.
b.
c.
d.
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: p. 305
OBJ: 6
TOP: Newborn Assessment—Skin (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).
c. Wash hands before touching each infant.
d. Wear a disposable gown when giving infant care.
ANS: C
Hand washing 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: p. 309
OBJ: 7
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: p. 291| Skill 12.1
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. Epstein‘s pearls
b. Milia
c. Stork bites
d. Mongolian spots
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ANS: D
Bluish skin discoloration over the sacral area of a newborn is a transitory condition called
Mongolian spots.
DIF: Cognitive Level: Comprehension
REF: pp. 302-305| Table 12.2
OBJ: 5
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 physician‘s attention first?
White blood cell count of 18,000
Hemoglobin of 18.5
Hematocrit of 56
Bilirubin of 15
a.
b.
c.
d.
ANS: D
A bilirubin of 15 is elevated and requires further immediate investigation.
DIF: Cognitive Level: Analysis
REF: p. 305 | Table 12.3
OBJ: 3
TOP: Labwork
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
MULTIPLE RESPONSE
1. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that
apply.)
Reflexes
Color
Heart rate
Respiration
Weight
a.
b.
c.
d.
e.
ANS: A, B, C, D
The Apgar score is a standardized method of evaluating the newborn‘s 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: p. 297
OBJ: 3
TOP: Apgar Score KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
2. 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
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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: p. 296
OBJ: 8
TOP: Noninvasive Pain Relief
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. 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 newborn‘s physiology? (Select 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: p. 298
OBJ: 4
TOP: Environmental Thermal Stress
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which interventions would be included in the nursing care of the newly circumcised infant?
(Select all that apply.)
Wash penis with warm water.
Wipe with alcohol swab.
Gently remove the yellow crust formation.
Apply diaper loosely.
Dress with simple bandage.
a.
b.
c.
d.
e.
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: pp. 301-302 | Patient Teaching Box
OBJ: 7
TOP: Circumcision Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. 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. Pincer grasping
ANS: A, B, C, D
Blinking, sneezing, gagging, and sucking reflexes are present in the full-term newborn. Pincer
grasp does not occur until between 8 and 12 months.
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DIF: Cognitive Level: Knowledge
REF: p. 290
OBJ: 2
TOP: Reflexes
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. 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 newborn‘s 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 infant‘s
sweat glands do not work effectively and allow very little fluid loss through sweat.
DIF: Cognitive Level: Comprehension
REF: p. 300
OBJ: 8
TOP: Dehydration KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Growth and Development
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Chapter 13: Preterm and Postterm Newborns
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is assessing a preterm infant. To what does the infant‘s level of maturation refer?
a. Actual time the fetus remained in the uterus
b. Age on the Dubowitz scoring system
c. Infant‘s 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: p. 321
OBJ: 1
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: p. 328
OBJ: 4
TOP: Jaundice
KEY: Nursing Process Step: Data Collection
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?
Weak or absent sucking or swallowing reflex
Inability to digest food properly
Refusal to take formula by mouth
Need for a larger quantity of formula at each feeding
a.
b.
c.
d.
ANS: A
When the preterm infant‘s sucking and swallowing reflexes are immature, gavage feedings
can be used to promote nutrition.
DIF: Cognitive Level: Comprehension
REF: p. 326
OBJ: 4
TOP: Preterm Infant—Nutrition
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
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in the preterm infant.
DIF: Cognitive Level: Knowledge
REF: p. 324
OBJ: 4
TOP: Respiratory Distress Syndrome
KEY: Nursing Process Step: Data Collection
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: p. 331
OBJ: 6
TOP: Preterm Infant—Nutrition
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: p. 324
OBJ: 4
TOP: Respiratory Distress Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. The apnea monitor indicates that a preterm infant is having an apneic episode. What is the
most appropriate nursing action in this situation?
Administer oxygen via a nasal cannula.
Gently rub the infant‘s feet or back.
Ventilate with an Ambu bag.
Perform nasopharyngeal suctioning.
a.
b.
c.
d.
ANS: B
Gently rubbing the infant‘s back, ankles, or feet may stimulate the infant to breathe.
DIF: Cognitive Level: Application
REF: p. 325
OBJ: 4
TOP: Preterm Infant—Apnea
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?
Seizures
Bradycardia
Dysrhythmias
Tetany
a.
b.
c.
d.
ANS: B
The infant receiving intravenous calcium gluconate should be monitored for bradycardia.
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DIF: Cognitive Level: Application
REF: p. 327
OBJ: 4
TOP: Hypocalcemia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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 infant‘s 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: p. 329
OBJ: 9
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?
Monitor arterial oxygen levels with a pulse oximeter.
Position the head slightly lower than the body.
Administer low concentrations of oxygen.
Keep the infant‘s eyes covered at all times.
a.
b.
c.
d.
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: p. 327
OBJ: 4
TOP: Retinopathy of Prematurity
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11. When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and
expiratory grunting. What do these findings indicate?
Respiratory distress syndrome
Postmaturity syndrome
Apneic episode
Cold stress
a.
b.
c.
d.
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: p. 324
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?
Assess for abdominal distention.
Decrease the amount of the next feeding.
Institute enteric precautions.
Get a culture of the next stool.
a.
b.
c.
d.
ANS: A
Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing
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enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to
bowel sounds.
DIF: Cognitive Level: Application
REF: p. 328
OBJ: 4
TOP: Necrotizing Enterocolitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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: p. 333
OBJ: 8
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
infant‘s glycogen stores are not adequate.
DIF: Cognitive Level: Analysis
REF: p. 327 |Nursing Tip
OBJ: 4
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 prematurely, asks the nurse if her daughter will
always be small 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: p. 333
OBJ: 8
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
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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
TOP: Immature Kidneys
REF: p. 328
OBJ: 4
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 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: p. 322
OBJ: 2
TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18. The nurse in a pediatrician‘s 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?
1st
2nd
3rd
4th
a.
b.
c.
d.
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: p. 333
OBJ: 2
TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. The mother of a postterm infant asks the nurse why the infant is being watched so closely.
What is the nurse‘s most appropriate response?
“The placenta does not function adequately as it ages.”
“Infants born postmaturely are generally large.”
“Delivery of the postterm infant is more difficult.”
“There is less amniotic fluid.”
a.
b.
c.
d.
ANS: A
Fetal distress may occur in the postterm infant because placental functioning becomes
inadequate with maturity.
DIF: Cognitive Level: Comprehension
REF: p. 334
OBJ: 9
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
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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: p. 326 | Nursing Tip
OBJ: 5
TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21. The nurse is caring for an infant born at 42 weeks. What would the physical assessment
reveal?
Dry, peeling skin
Minimal hair on the head
Short, rough nails
Abundant lanugo on the body
a.
b.
c.
d.
ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling.
DIF: Cognitive Level: Comprehension
REF: p. 334
OBJ: 9
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: p. 321
OBJ: 1
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?
Every hour
Every 2 hours
Every 4 hours
Every 8 hours
a.
b.
c.
d.
ANS: B
The temperature of the incubator is adjusted to a level that will maintain an optimal body
temperature in the infant. Smaller infants may require higher incubator temperatures. The
nurse records the temperature of the infant and the incubator every 2 hours. The infant‘s
temperature is monitored with a heat-sensitive probe that is taped to the abdomen.
DIF: Cognitive Level: Comprehension
TOP: Thermoregulation
REF: p. 329
OBJ: 5
KEY: Nursing Process Step: Implementation
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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: p. 334
OBJ: 9
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?
Term
Small for gestational age
Large for gestational age
Late preterm
a.
b.
c.
d.
ANS: C
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: p. 321
OBJ: 2
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: p. 324
OBJ: 4
TOP: Respiratory Distress Syndrome
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. The nurse knows that a postterm infant may experience which potential problems? (Select all
that apply.)
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a.
b.
c.
d.
e.
Seizures
Asphyxia
Paralysis
Visual defects
Polycythemia
ANS: A, B, E
The postterm infant should be assessed closely for indication of asphyxia, seizures, and
polycythemia.
DIF: Cognitive Level: Comprehension
REF: p. 334
OBJ: 9
TOP: Potential Problems of the Postterm Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. 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.)
Placenta previa
Gestational diabetes
Pregnancy-induced hypertension
Hyperemesis gravidarum
Chloasma
a.
b.
c.
d.
e.
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: p. 321
OBJ: 3
TOP: Preterm Birth
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
3. The nurse assesses a preterm infant in the NICU. What signs should be reported to the
physician? (Select all that apply.)
Paleness
Transparent skin
Superficial scalp veins
Vomiting
Bulging fontanelles
a.
b.
c.
d.
e.
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: p. 332 |Table 13.1
OBJ: 4
TOP: Potential Problems of the Preterm Infant
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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. 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: p. 324
OBJ: 4
TOP: Surfactant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
Chapter 14: The Newborn with a Perinatal Injury or Congenital Malformation
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. What occurrence results from obstruction within the ventricles of the brain or inadequate
reabsorption of cerebrospinal fluid?
Meningitis
Meningocele
Spina bifida occulta
Hydrocephalus
a.
b.
c.
d.
ANS: D
Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the
brain.
DIF: Cognitive Level: Knowledge
REF: p. 338
OBJ: 1 | 2 | 4
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?
Align the limbs.
Support the head.
Keep the head lower than the hip.
Check intake and output.
a.
b.
c.
d.
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 child to prevent injury to the neck.
DIF: Cognitive Level: Application
TOP: Hydrocephalus
REF: p. 340
OBJ: 5
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse observes that the infant‘s anterior fontanelle is bulging after placement of a
ventriculoperitoneal shunt. How should the nurse position this infant?
Prone, with the head of the bed elevated
Supine, with the head flat
Side-lying on the operative side
In a semi-Fowler‘s position
a.
b.
c.
d.
ANS: D
If the fontanelles are bulging, the child will be positioned in a semi-Fowler‘s position to
promote drainage from the ventricles through the shunt.
DIF: Cognitive Level: Application
REF: p. 340
OBJ: 5
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-lying position in a quiet atmosphere to reduce the incidence of
vomiting.
DIF: Cognitive Level: Application
REF: p. 340
OBJ: 5
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?
Keep the sac dry.
Diaper snugly.
Position prone in an incubator.
Move from side to side every hour.
a.
b.
c.
d.
ANS: C
The infant is placed prone in a humidified incubator, and the sac is covered with dressings of
sterile saline. The infant‘s hips are kept lower than the lesion, and the infant is usually not in
diapers.
DIF: Cognitive Level: Analysis
REF: p. 342
OBJ: 7
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 child‘s head.
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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 a VP shunt may be indicative of malabsorption
of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum.
DIF: Cognitive Level: Application
REF: p. 340
OBJ: 5
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?
Facial paralysis
Ear infections
Increased intracranial pressure (ICP)
Drooling
a.
b.
c.
d.
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: p. 344
OBJ: 8
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.
DIF: Cognitive Level: Application
REF: p. 344
OBJ: 8
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?
“We are feeding the baby with a dropper for 2 weeks.”
“We resumed bottle feeding after discharge.”
“We started the baby on solid food yesterday.”
“The baby is drinking well from a straw.”
a.
b.
c.
d.
ANS: A
The infant is fed with a dropper until the incision is completely healed about 1 to 2 weeks
after surgery.
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DIF: Cognitive Level: Application
REF: p. 344
OBJ: 8
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?
Feed solid foods with the spoon at the side of the mouth.
Puree foods and offer them through a straw.
Place small bites of food in the mouth with a tongue blade.
Offer small, frequent meals of finger foods.
a.
b.
c.
d.
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.
DIF: Cognitive Level: Application
REF: p. 345
OBJ: 8
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?
Hypotonicity of the leg muscles
One leg is shorter than the other
Broadening and flattening of the buttocks
Two skinfolds on the back of each thigh
a.
b.
c.
d.
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: pp. 346-347 |Figure 14.9
OBJ: 9
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 Pavlik harness
A body spica cast
Traction
Triple-diapering
a.
b.
c.
d.
ANS: A
In infants who are more than 2 months of age, longer-term immobilization with a Pavlik
harness is required.
DIF: Cognitive Level: Comprehension
REF: p. 347 | Figure 14.10
OBJ: 9
TOP: Developmental Hip Dysplasia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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?
In the first 24 hours of life
After 2 to 3 days
At 4 to 6 weeks of age
At 2 months of age
a.
b.
c.
d.
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: p. 350
OBJ: 10
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?
Lifelong high-protein diet
A formula that is low in the amino acid leucine
A soy-based formula
Substitute Lofenalac for some protein foods
a.
b.
c.
d.
ANS: D
A synthetic food providing enough protein for growth and tissue repair, but little
phenylalanine, is substituted for natural protein foods.
DIF: Cognitive Level: Comprehension
REF: p. 350
OBJ: 10
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: p. 353
OBJ: 11
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.
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d. Change the child‘s position frequently.
ANS: D
The child‘s position must be changed frequently to relieve pressure and promote circulation.
DIF: Cognitive Level: Application
TOP: Developmental Hip Dysplasia
MSC: NCLEX: Physiological Integrity
REF: p. 348
OBJ: 9
KEY: Nursing Process Step: Implementation
17. The nurse is caring for an Rh-negative mother on the labor and birth unit. What scenario
indicates this patient will require RhoGAM administration?
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: p. 354
OBJ: 12
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 nurse‘s
best response?
“The light increases the infant‘s metabolism.”
“The light stimulates liver function.”
“The light dilates blood vessels.”
“The light breaks down bilirubin.”
a.
b.
c.
d.
ANS: D
Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which
can lead to serious brain damage. The light breaks down excess bilirubin so that it can be
excreted.
DIF: Cognitive Level: Application
REF: p. 355
OBJ: 14
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.
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DIF: Cognitive Level: Comprehension
REF: p. 343
OBJ: 8
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 infant‘s head with a hat.
b. Dress the infant lightly in a T-shirt.
c. Keep the infant‘s eyes covered.
d. Reposition the infant at least every 4 to 8 hours.
ANS: C
The infant‘s eyes are protected with patches to prevent damage from the high-intensity lights.
DIF: Cognitive Level: Application
REF: p. 357 |NCP 14.2
OBJ: 13
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?
Hypoglycemia
Erythroblastosis fetalis
Intracranial hemorrhage
Pancreatic failure
a.
b.
c.
d.
ANS: A
The newborn of a mother with diabetes is prone to hypoglycemia.
DIF: Cognitive Level: Application
REF: p. 360
OBJ: 15
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 the head of the femur 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: p. 346
OBJ: 9
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
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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: p. 352
OBJ: 11
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
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 Turner‘s
syndrome or Klinefelter‘s syndrome may have impaired physical growth and sexual
development. Malformations at birth include several types of structural defects.
DIF: Cognitive Level: Knowledge
REF: p. 337 | Box 14.1
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
1. What characteristics are typical in a child diagnosed with Down syndrome? (Select all that
apply.)
Close-set eyes
Simian creases
Wide-spaced front teeth
Protruding tongue
Curved, small fingers
a.
b.
c.
d.
e.
ANS: A, B, D, E
Children with Down syndrome have close-set upturned eyes, simian creases in palms of
hands, protruding tongue, 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: p. 351 | Figure 14.12
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OBJ: 11
TOP: Features of Down Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What will the nurse include in the plan of care when caring for an infant with an intracranial
hemorrhage? (Select all that apply.)
Keep positioned with head elevated.
Feed slowly to reduce possibility of vomiting.
Stimulate often to maintain level of consciousness.
Hold and coddle frequently to stimulate.
Observe for increased intracranial pressure.
a.
b.
c.
d.
e.
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: p. 359
OBJ: 2
TOP: Intracranial Hemorrhage
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. 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.)
Keep cast uncovered to allow drying.
Check toes for capillary refill.
Circle with a pen any area of bleeding on the cast.
Keep casted leg lowered.
Observe for skin irritation.
a.
b.
c.
d.
e.
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: pp. 345-346 OBJ: 2
TOP: Repair of Clubfoot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the
newborn of a mother who took opioids during pregnancy. 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
TOP: Neonatal Abstinence
REF: p. 360
OBJ: 2
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Physiological Integrity: Reduction of Risk
5. What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware
of? (Select all that apply.)
High-pitched cry
Unequal pupils
Bulging fontanelles
Diarrhea
Hiccups
a.
b.
c.
d.
e.
ANS: A, B, C
Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles.
DIF: Cognitive Level: Knowledge
REF: p. 340 | Nursing Tip
OBJ: 4
TOP: Signs of ICP KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6. 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 12th 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: p. 341
OBJ: 6
TOP: Prevention of Neural Tube Defects KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
7. 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
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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: p. 360
OBJ: 15
TOP: Macrosomic Newborn
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
8. The home health nurse is educating parents on home phototherapy. What will the nurse
include when providing information to these parents? (Select all that apply.)
a.
b.
c.
d.
e.
Cover the infant‘s eyes when under the light.
Use a three-prong plug.
Keep a diaper in place.
Place the light source on an absorbent surface.
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 infant‘s eyes when under the light.
DIF: Cognitive Level: Application
REF: p. 360 | Box 14.4
OBJ: 14
TOP: Home Phototherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
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Chapter 15: An Overview of Growth, Development, and Nutrition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: p. 365
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 individual‘s pattern of
behavior?
a.
b.
c.
d.
Environment
Heredity
Personality
Experience
ANS: C
One definition of personality states that it is a unique organization of characteristics that
determines the individual‘s typical or recurrent pattern of behavior.
DIF: Cognitive Level: Knowledge
REF: p. 374
OBJ: 1
TOP: Personality Development
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. An infant‘s birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at
6 months?
12 pounds
15 pounds
18 pounds
22 pounds
a.
b.
c.
d.
ANS: B
An infant usually doubles his or her birth weight by 5 to 6 months.
DIF: Cognitive Level: Analysis
REF: p. 366
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 sibling‘s weight at the same age was in the
75th percentile.
ANS: A
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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: p. 369
OBJ: 4
TOP: Growth
KEY: Nursing Process Step: Data Collection
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: p. 372 | Table 15.1
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 infant 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: p. 388
OBJ: 10
TOP: Dentition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. At a well-baby visit, parents of a 6-month-old infant ask when to take the infant for the first
dental visit. What is the nurse‘s 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: p. 388
OBJ: 10
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
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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: p. 389
OBJ: 10
TOP: Dentition
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. A mother asks the nurse how much food should be offered to her 2-year-old child. What is a
good rule of thumb for serving size (in tablespoons) per year of age?
2
3
4
5
a.
b.
c.
d.
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: p. 387
OBJ: 9
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 child‘s nutritional status reveals the child is alert, with shiny hair, firm
gums, firm mucous membranes, and regular elimination. How would this child‘s 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: p. 385
OBJ: 9
TOP: Nutrition
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. The nurse encourages a Puerto Rican family to bring food to a child because he is not eating
the food served on his hospital tray. What can the nurse expect the child to eat?
Dried beans mixed with rice
Crisp vegetables
Spaghetti and meatballs
Wild berries, roots, and seeds
a.
b.
c.
d.
ANS: A
A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice.
DIF: Cognitive Level: Comprehension
REF: p. 383 | Table 15.6
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 toddler 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
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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: p. 384
OBJ: 2
TOP: Feeding the Healthy Child
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13. What activity would the nurse choose to meet Erikson‘s developmental task of industry when
caring for a 7-year-old child?
Completing a 50-piece jigsaw puzzle
Looking at a comic book
Playing a game of “I Spy” with the nurse
Coloring a picture in a coloring book
a.
b.
c.
d.
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: p. 374 | Table 15.4
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 Piaget‘s concrete operational thinking?
a. A 2-year-old child says, “It‘s nighttime” when his room is darkened.
b. A 4-year-old child refers to the hospital as “my house.”
c. A 5-year-old child coloring a picture of a puppy says, “This is my puppy.”
d. A 7-year-old child says, “I am sick because I have germs in my chest.”
ANS: D
The 7-year-old child‘s 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: p. 374 | Table 15.3
OBJ: 8
TOP: Cognitive Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and 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.
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DIF: Cognitive Level: Comprehension
REF: p. 383 | Table 15.6
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: p. 390
OBJ: 10
TOP: Loss of Tooth
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
17. The mother of a 7-month-old infant states, “The baby is eating food now. Should I give him
regular milk, too?” What is the nurse‘s best response?
“You should give the baby low-fat milk.”
“Try the milk. See if he has any digestive problems.”
“Continue breast milk or iron-fortified formula until 1 year of age.”
“At this age, infants can tolerate lactose-free or soy-based milk.”
a.
b.
c.
d.
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: p. 380
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: p. 391| Table 15.8
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?
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a.
b.
c.
d.
Indecision
Considering the answer in silence
Shyness with strangers
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: p. 370 | Table 15.2
OBJ: 7
TOP: Ethnic Considerations—American 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 child‘s language development?
a. Heredity
b. Sex
c. Mother‘s 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.
DIF: Cognitive Level: Analysis
REF: p. 369
OBJ: 5
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: p. 374 | Table 15.3
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 child‘s genitals
c. Touching the child‘s head
d. Using cool water
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ANS: C
The Vietnamese are very sensitive about anyone touching a child‘s head because that is where
consciousness lies.
DIF: Cognitive Level: Application
REF: p. 367 | Table 15.2
OBJ: 7
TOP: Ethnic Considerations—Vietnamese
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: p. 385 | Skill 15.2
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?
Jack-in-the-box
Book of nursery rhymes
Model airport with toy planes
Model car construction kit
a.
b.
c.
d.
ANS: C
At this age children are into creative play. The model airport with toy planes is the most
developmentally appropriate.
DIF: Cognitive Level: Application
REF: p. 391 | Table 15.8
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.
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DIF: Cognitive Level: Application
REF: p. 391 | Table 15.8
OBJ: 14
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 child‘s 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
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 child may sleep 10 hours during the night and
have only one short daytime nap. The 7-year-old child 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: p. 368
OBJ: 5
TOP: Sleep
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
MULTIPLE RESPONSE
1. 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 higher metabolic rate. All of their organ systems are not mature.
DIF: Cognitive Level: Comprehension
REF: p. 363
OBJ: 3
TOP: Adult Versus Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. What approaches should the nurse suggest for introducing a toddler to new foods? (Select all
that apply.)
Serve one food at a time.
Avoid showing personal likes or dislikes.
Offer foods in small amounts, less than a teaspoon.
Entice the toddler to eat with sweets.
Serve food warm.
a.
b.
c.
d.
e.
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.
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DIF: Cognitive Level: Comprehension
REF: pp. 384-385 OBJ: 9
TOP: Solid Food
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select
all that apply.)
Bubble gum
Chocolate-covered peanuts
Raw vegetables
Cheese
Dried fruits
a.
b.
c.
d.
e.
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: p. 378
OBJ: 9
TOP: Healthy Snacks
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse suggests to the parents of an obese 10-year-old child that they use the Portion Plate
for Kids place mat. 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 place mat that uses common objects such as a deck of playing
cards or a baseball to measure serving portions.
DIF: Cognitive Level: Comprehension
REF: p. 378
OBJ: 9
TOP: Portion Plate for Kids
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. 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
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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 child‘s relationships with family members. Any plan 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: p. 391
OBJ: 11 | 13 | 15
TOP: Play
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6. 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: p. 392
OBJ: 13
TOP: Computer Play
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 16: The Infant
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A mother calls the pediatrician‘s 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 infant‘s 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: p. 403
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: p. 392 | Box 16.1
OBJ: 5
TOP: Fontanelle
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. At what age does an infant‘s 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: p. 403 | Box 16.1
OBJ: 5
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
OBJ: 5
TOP: Sitting Alone
REF: p. 401 | Box 16.1
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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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: p. 403 | Box 16.1
OBJ: 4
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 nurse‘s most accurate response?
a. 5 months
b. 9 months
c. 1 year
d. 2 years
ANS: B
The infant can usually drink from a cup when it is offered at about 9 months.
DIF: Cognitive Level: Comprehension
REF: p. 395 | Box 16.1
OBJ: 9 | 14
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 infant to be able to accomplish?
a. Hold a cup.
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: p. 400 | Box 16.1
OBJ: 4
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.
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DIF: Cognitive Level: Analysis
REF: p. 401 | Box 16.1
OBJ: 4
TOP: Head Control
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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 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: p. 400 | Box 16.1
OBJ: 4
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: p. 410
OBJ: 9 | 13
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?
Lower central incisors
Upper central incisors
Lower lateral incisors
Upper lateral incisors
a.
b.
c.
d.
ANS: A
The first teeth to erupt, usually at about 7 months, are the lower central incisors.
DIF: Cognitive Level: Knowledge
REF: p. 401 | Box 16.1
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?
Speaking in 2-word sentences
Grasping objects with palmar grasp
Creeping along the floor
Beginning to use a spoon rather sloppily
a.
b.
c.
d.
ANS: C
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The 9-month-old infant tries to creep, has developed pincer movement, and can grasp a spoon
without keeping food on it.
DIF: Cognitive Level: Analysis
REF: p. 401 | Box 16.1
OBJ: 4
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?
a. “I‘ve been mixing rice cereal and formula in the baby‘s 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 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: p. 410 | Nursing Tip
OBJ: 9
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 infant is lethargic. What is the best action
the nurse can advise this mother to implement?
Keep the infant‘s room well lit.
Rub the infant‘s soles vigorously.
Offer the infant a pacifier.
Handle the infant slowly and gently.
a.
b.
c.
d.
ANS: D
Some infants respond to stimulating environments by shutting down. Move and handle infants
slowly and gently.
DIF: Cognitive Level: Application
REF: p. 404
OBJ: 6
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
infant. Which statement made by the mother would indicate an unsafe behavior?
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: p. 412
OBJ: 16
TOP: Infant Safety
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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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?
The pincer grasp
A grasp reflex
Prehension ability
The parachute reflex
a.
b.
c.
d.
ANS: A
By 1 year, the pincer-grasp coordination of index finger and thumb is well established.
DIF: Cognitive Level: Comprehension
REF: p. 396
OBJ: 4
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?
Use commercial diaper wipes to clean the area.
Apply a protective ointment on the area.
Change the infant‘s diaper less frequently.
Keep the diaper area covered all of the time.
a.
b.
c.
d.
ANS: B
A protective ointment can be applied when the skin in the diaper area appears pink and
irritated.
DIF: Cognitive Level: Application
REF: p. 405
OBJ: 6
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 infant‘s 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: p. 404
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 1-year-old infant?
a. Ride a tricycle.
b. Spend time in an infant swing.
c. Play with push-pull toys.
d. Read large picture books.
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ANS: C
Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old infant.
DIF: Cognitive Level: Analysis
REF: p. 413 | Table 16.3
OBJ: 17
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 infant understands infant sleep
patterns?
“I put the baby in my bed until she falls asleep, then I put her in her crib.”
“I let the baby skip an afternoon nap so that she will fall asleep earlier.”
“I put the pacifier in the crib so that she can find it when she wakes up.”
“I rock the baby back to sleep if she wakes up at night.”
a.
b.
c.
d.
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: p. 404
OBJ: 8
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
b. Holding the infant in a football hold, cradling the head
c. Seating the infant in a stroller in an upright position
d. Placing the infant downward into the crib
ANS: D
The infant, when placed downward in a prone position, will protectively extend the arms.
DIF: Cognitive Level: Comprehension
REF: p. 396
OBJ: 4
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
It is necessary to offer iron-rich formula to the children when they exhausted maternal iron
stores.
DIF: Cognitive Level: Comprehension
REF: p. 407
OBJ: 12
TOP: Iron Supplement
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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23. The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the
nurse report to the physician immediately?
Respiratory rate of 60 breaths/minute
Pulse rate of 100 beats/minute
Minimal verbalization
Fussy behavior
a.
b.
c.
d.
ANS: A
Respirations of a 1-year-old infant should be 20 to 40 breaths/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: p. 403 | Box 16.1
OBJ: 3
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?
Every 2 to 3 hours
Every 4 to 6 hours
Every 6 to 8 hours
Every 8 to 10 hours
a.
b.
c.
d.
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: p. 407
OBJ: 12
TOP: 12-Month-Old Physical Characteristics
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. The nurse cautions that children who have unmet hunger needs will likely display which
characteristic(s)? (Select all that apply.)
Irritability
Ineffective feeding patterns
No predictable sleep–wake cycle
Distrust
Effective parent bonding
a.
b.
c.
d.
e.
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: p. 395
OBJ: 9
TOP: Hunger
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. The nurse is preparing to outline principles of discipline for parents of an infant. What
information should the nurse include? (Select all that apply.)
Firmly say “No.”
Distract the child to another activity.
Bribe the child with a sweet treat.
Remain consistent.
Ignore the child until behavior improves.
a.
b.
c.
d.
e.
ANS: A, B, D
Parental approval is important to the infant, and setting limits early is essential. Principles of
discipline at this age include the following: lowering the voice to say no firmly, removing the
child from the situation, distraction, and consistency.
DIF: Cognitive Level: Comprehension
REF: p. 398 | Nursing Tip
OBJ: 2
TOP: Discipline
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. 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 while indoors.
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: p. 412
OBJ: 16
TOP: Fall Prevention
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4. The nurse is aware that the 7-month-old infant can signal feeding readiness by which
action(s)? (Select all that apply.)
Pulling spoon toward mouth
Biting at spoon with upper and lower incisors
Pointing to food bowl
Bouncing up and down with excitement at sight of food
Manipulating finger foods
a.
b.
c.
d.
e.
ANS: A, E
The 7-month-old infant pulls the spoon toward his or her mouth and can manipulate finger
foods. The 7-month-old infant 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: p. 401 | Box 16.1
OBJ: 14
TOP: Feeding Skills
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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5. The nurse is educating parents of a 2-month-old infant about immunizations. What
immunizations against illness should their child receive? (Select all that apply.)
Pertussis (whooping cough)
Influenza
Diphtheria
Tetanus
Polio
a.
b.
c.
d.
e.
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: p. 399| Box 16.1
OBJ: 6
TOP: Immunizations
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
6. 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
d. Infant‘s 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; parent–child interaction; and cultural and ethnic
practices is important. Sex of the infant does not enter into nutritional education.
DIF: Cognitive Level: Comprehension
REF: p. 406
OBJ: 10
TOP: Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. 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.)
Boil foods in a large amount of water.
Do not freeze foods.
Add 1 teaspoon of salt per cup.
Puree food in electric blender.
Add sugar sparingly.
a.
b.
c.
d.
e.
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: p. 409 |Health Promotion
OBJ: 13
TOP: Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 17: The Toddler
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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?
Has temper tantrums.
Feeds self sloppily.
Walks by holding onto furniture.
Speaks in short sentences.
a.
b.
c.
d.
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: p. 415 | Table 17.1
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 child can jump with both feet. The remaining achievements occur after 2 years
of age.
DIF: Cognitive Level: Comprehension
REF: p. 415 | Table 17.1
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: p. 419
OBJ: 2
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?
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a.
b.
c.
d.
Solitary
Parallel
Associative
Cooperative
ANS: B
Toddlers engage in parallel play. Children play next to, but not with, each other.
DIF: Cognitive Level: Comprehension
REF: p. 423
OBJ: 11
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?
Adhere to a rigid schedule because the toddler is ritualistic.
Limit-setting should include praise.
Shoes should fit snugly at the toe and arch.
Dress the toddler in pants with a zipper so that he or she can learn to zip and unzip
clothes.
a.
b.
c.
d.
ANS: B
Limit-setting should include praise as well as disapproval for undesired behavior.
DIF: Cognitive Level: Application
REF: p. 419
OBJ: 6
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 child 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: p. 422
OBJ: 9
TOP: Quiet Time KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. How would the nurse advise a parent who states, “I never know how much food to feed my
child”?
Serving sizes should not exceed 1 teaspoon of each type of food.
Food quantities must be carefully measured to avoid overfeeding.
Use 1 tablespoon of each food for each year of age as a guideline.
A toddler should eat three balanced meals. Snacks are not necessary.
a.
b.
c.
d.
ANS: C
A tablespoon of each type of food for each year of age is a good guideline to follow when
determining serving sizes.
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DIF: Cognitive Level: Application
REF: p. 422
OBJ: 9
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?
Willing to sit on the potty for 15 to 20 minutes
Dry in the daytime for 4-hour periods
Able to communicate that he or she is wet
Curious about bathroom activities
a.
b.
c.
d.
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: p. 419
OBJ: 8
TOP: Toilet Independence
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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 child enjoys playing with objects that can be pushed or pulled.
DIF: Cognitive Level: Application
REF: p. 427
OBJ: 11
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 child‘s mother to encourage a toddler to practice
independence?
Offer a variety of items to choose from to stimulate his mind.
Allow the child to determine his own daily routine.
Offer him a choice between two items.
Set the routine herself, but discuss with her toddler how he or she would have done
it differently.
a.
b.
c.
d.
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: p. 415
OBJ: 4
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: p. 424 | Health Promotion Box
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: p. 424 | Health Promotion Box
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 child?
a. Temperature of 37.1C (98.8F)
b. Pulse at 100 beats/minute
c. Respirations of 36 breaths/minute
d. Blood pressure of 90/60 mm Hg
ANS: C
In the toddler period, the respiratory rate decreases to 25 breaths/minute.
DIF: Cognitive Level: Analysis
REF: pp. 416-417 OBJ: 2
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
child?
A 900-word vocabulary
Use of two-word sentences
Use of pronouns and prepositions
100% of speech is understandable
a.
b.
c.
d.
ANS: B
The 2-year-old child should be using two-word sentences.
DIF: Cognitive Level: Analysis
REF: p. 418 | Table 17.2
OBJ: 5
TOP: Speech Development
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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 child. How
many minutes will the nurse indicate is appropriate for a child of this age?
3
6
10
15
a.
b.
c.
d.
ANS: A
Timing for time-out is usually based on 1 minute per year of age.
DIF: Cognitive Level: Comprehension
REF: p. 419
OBJ: 6
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 daughter‘s 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
TOP: Nutrition Counseling
MSC: NCLEX: Physiological Integrity
REF: p. 422
OBJ: 9
KEY: Nursing Process Step: Data Collection
17. How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to
begin bladder training?
1
2
3
4
a.
b.
c.
d.
ANS: B
If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.
DIF: Cognitive Level: Comprehension
REF: p. 421
OBJ: 8
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 toddler‘s 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
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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: p. 415
OBJ: 1 | 2
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 toddler. 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
ANS: D
The expected weight of a
-year-old toddler is four times the birth weight.
DIF: Cognitive Level: Comprehension
REF: p. 415
OBJ: 2
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 child‘s 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 child‘s attention and is especially important when the
child is frightened.
DIF: Cognitive Level: Comprehension
REF: p. 421
OBJ: 2
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
Toddlers have a shorter attention span than preschoolers and are prone to investigate other
opportunities in the environment that may put them in harm‘s way. Toddlers are more
interested in parallel play.
DIF: Cognitive Level: Comprehension
REF: p. 423
TOP: Day Care
KEY: Nursing Process Step: N/A
OBJ: 2
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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?
Does not walk independently
Prefers finger feeding
Limited to single words
Is unable to climb steps
a.
b.
c.
d.
ANS: A
A child should be walking independently by 16 months. 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: p. 416 | Table 17.1
OBJ: 2
TOP: Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. 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 child‘s feet to touch floor
b. Sturdy and stable
c. Supportive of child‘s back and arms
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 child‘s back and arms. The
composition is not important as long as it is stable.
DIF: Cognitive Level: Comprehension
REF: p. 421
OBJ: 8
TOP: Potty Chairs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. The nurse suggests offering which food(s) to support the toddler‘s 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: p. 422
OBJ: 9
TOP: Self-Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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3. The nurse points out which physiological change(s) in the toddler that serve(s) as protection
against disease? (Select all that apply.)
Toughening of the skin
Increased capillary response for thermoregulation
Stabilization of body temperature
Elevation in white blood cell count
Enlarged adenoids and tonsils
a.
b.
c.
d.
e.
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: p. 416
OBJ: 2
TOP: Physiological Changes
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. 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.)
Stress increases fear.
Rituals help deal with fear.
Teasing the child can decrease fear.
Once fear is learned it is difficult to eliminate.
Adults should openly share their fears.
a.
b.
c.
d.
e.
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: p. 419
OBJ: 7
TOP: Fear
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. The nurse assessing a 2-year-old is satisfied to see that the present weight of the child is
times their birth weight.
ANS:
3
The birth weight has usually tripled by the time the child is 2 years of age.
DIF: Cognitive Level: Comprehension
REF: p. 415
OBJ: 2
TOP: Tripled Birth Weight
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 18: The Preschool Child
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: p. 434
OBJ: 3
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 nurse‘s 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: p. 434
OBJ: 10
TOP: Masturbation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. A preschool 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: p. 431
OBJ: 1 | 3 | 4
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 child?
a. Setting the table with paper plates
b. Washing the dirty knives
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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: p. 437
OBJ: 3
TOP: Development—Safety
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 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: p. 432 | Table 18.1
OBJ: 3
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 children‘s reaction should their grandmother die. What
understanding will guide the nurse‘s response?
a. Children are unlikely to notice their grandmother‘s absence if no one reminds
them.
b. Young children often understand that other people die, but do not equate it with
themselves.
c. The children‘s 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 children become curious about death and dying. They may
realize that others die, but they do not relate death to themselves.
DIF: Cognitive Level: Comprehension
REF: p. 435
OBJ: 7
TOP: Concept of Death
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. What is the most appropriate intervention when dealing with occasional aggression in a
4-year-old child?
Have the child take a time-out in the corner for 4 minutes.
Spank the child at the time of the incident.
Take away television privileges for the day.
Send the child to his room for 30 minutes.
a.
b.
c.
d.
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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: pp. 436-437 OBJ: 3
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 child‘s fingers whenever he sucks his thumb is most
effective.”
d. “Thumb-sucking is detrimental to the eruption of the child‘s 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: p. 438
OBJ: 10
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?
a. Enjoying rough and tumble play
b. Playing well-organized games
c. Following rules
d. Preferring inside activities
ANS: C
The 5-year-old child 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: p. 432 | Table 18.1
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?
“Make up funny words for body parts.”
“Distract the child with a toy if they ask about sex.”
“Answer their questions when they ask.”
“Tell them to ask you again when they are 6 years old.”
a.
b.
c.
d.
ANS: C
Parents should provide sex education at the time the child asks about sex.
DIF: Cognitive Level: Analysis
REF: pp. 432-434 OBJ: 10
TOP: Sexual Curiosity
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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11. What type of play is most appropriate when planning care for a child with moderate
intellectual deficiency?
Exercise leg and arm muscles.
Be educationally oriented to make up for lost time.
Be adjusted to mental age rather than chronological age.
Involve contact sports and aggressive physical activity with other children.
a.
b.
c.
d.
ANS: C
The nurse must consider the child‘s mental age rather than her chronological age when
selecting toys for play.
DIF: Cognitive Level: Application
REF: p. 442
OBJ: 14
TOP: Play
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12. What is the nurse‘s best advice to a parent about a preschooler‘s “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: pp. 441-442 OBJ: 3 | 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
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: p. 439
OBJ: 10
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.
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DIF: Cognitive Level: Application
REF: p. 441
OBJ: 13
TOP: Play
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
-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 parent‘s comment, what does the nurse suspect?
a. Age-appropriate language development
b. An expressive language delay
c. A receptive language delay
d. A potential hearing deficit
15. The parent of a
ANS: B
An expressive language delay is suspected when the child understands spoken language but is
not talking.
DIF: Cognitive Level: Application
REF: p. 434 | Table 18.3
OBJ: 5
TOP: Language Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
-year-old child tells the nurse, “Bedtime is difficult. I can‘t get my son to
go to bed at night.” The nurse and the child‘s 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.
16. The parent of a
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: p. 434
OBJ: 6
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
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: p. 435
OBJ: 3
TOP: Fear
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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18. A 4-year-old child tells the nurse she will not eat peas because they are green. Of what is this
an example?
Egocentrism
Artificialism
Animism
Centering
a.
b.
c.
d.
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: p. 431
OBJ: 3
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 Piaget‘s theory?
Egocentrism
Artificialism
Animism
Intuition
a.
b.
c.
d.
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: p. 431
OBJ: 4
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: p. 431
OBJ: 5
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 in house, one playing the role of the dad and the other
playing the role of 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
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ANS: A
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: p. 435
OBJ: 13
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?
“I continue to provide a great deal of indirect supervision for my child.”
“My stairway is always free of clutter.”
“I only leave my child in the car for brief moments.”
“Medications are kept in a locked cabinet.”
a.
b.
c.
d.
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: p. 440
OBJ: 12
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 child‘s 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
d. Articulation disorder
ANS: D
When parents are the only people to understand their preschool child, an articulation disorder
is suspected (see Table 18-3).
DIF: Cognitive Level: Application
REF: p. 434 | Table 18.3
OBJ: 5
TOP: Speech Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. 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. Offer an emotional outlet.
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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 interacting with other children. Play employs
the use of magical thinking.
DIF: Cognitive Level: Knowledge
REF: p. 440
OBJ: 13
TOP: Purpose of Play
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. What developmental milestone(s) assist the 5-year-old boy toward developing his sexual
identity? (Select all that apply.)
Begins to be less focused on his mother.
Ignores both parents totally.
Regresses to a more infantile level.
Forms a romantic attachment to the mother.
Identifies with the parent of the same sex.
a.
b.
c.
d.
e.
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, “I‘m going to marry my mother.” A little girl might
say, “I‘m going to marry my daddy.”
DIF: Cognitive Level: Application
REF: p. 435
OBJ: 2
TOP: Romantic Attachment to Parent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. Which bedtime preparation rituals are the most appropriate for the nurse to suggest? (Select
all that apply.)
Telling a story
Placing a favorite toy in bed
Placing a glass of water at the bedside
Turning on a night-light
Playing energetically
a.
b.
c.
d.
e.
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: p. 434
OBJ: 6
TOP: Bedtime Habits
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. The nurse points out what advantage(s) of a nursery school or preschool experience? (Select
all that apply.)
Increasing self-confidence
Fostering group cooperation
Detecting adjustment problems
Attainment of toilet training skills
a.
b.
c.
d.
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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: p. 439
OBJ: 12
TOP: Advantages of Nursery School
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. 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, and attention span. Appetite remains inconsistent.
DIF: Cognitive Level: Comprehension
REF: p. 430
OBJ: 2
TOP: Major Developmental Tasks
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. When planning an activity for a 3-year-old child, 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: p. 432 | Table 18.1
OBJ: 3
TOP: Attention Span of Preschooler
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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Chapter 19: The School-Age Child
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: pp. 445-446 OBJ: 3
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: p. 445
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: p. 445
OBJ: 3
TOP: Social Development—Play
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 Erikson‘s
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.
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DIF: Cognitive Level: Analysis
REF: p. 446 | Box 19.1
OBJ: 3
TOP: Psychosocial Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. The parents of an 8-year-old child tell the nurse the child wakes the household crying out
during his frequent nightmares. What is the nurse‘s most helpful response to explain
nightmares?
a. They are a normal extension of the child‘s 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 child are an extension of their characteristic fear
of mutilation.
DIF: Cognitive Level: Comprehension
REF: p. 455 | Table 19.3
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?
Handheld video game
MP3 player
Adventure book
Jigsaw puzzle
a.
b.
c.
d.
ANS: A
The 6-year-old child can perform numerous feats that require muscle coordination. At this
age, the handheld video game will offer competition without overexertion.
DIF: Cognitive Level: Analysis
REF: p. 449
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 with the parents of a 6-year-old girl who will soon
be starting first grade. What statement by the girl‘s father leads the nurse to determine that the
parents understood the information?
a. “We should put a stop to her thumb-sucking.”
b. “We‘ll have a talk about what school is like.”
c. “We will let her walk to the bus stop by herself.”
d. “We‘ll 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: p. 449 | Parent Teaching Box
OBJ: 4
TOP: Parental Guidance for Starting School
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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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?
He sleeps only 6 to 7 hours a night.
He eats eggs every day.
He has a new dog.
He plays about 1 to 3 hours each evening.
a.
b.
c.
d.
ANS: A
The 9-year-old child requires about 10 hours of sleep per night.
DIF: Cognitive Level: Application
REF: p. 452
OBJ: 3
TOP: Nine-Year-Old
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9. A parent asked the nurse, “At what age are children capable of assuming more responsibility
for personal belongings?” What is the nurse‘s 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 child is dependable and assumes more responsibility for personal belongings.
DIF: Cognitive Level: Comprehension
REF: p. 452
OBJ: 3
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: p. 450 | Nursing Tip
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 wants a dog. His 10-year-old brother has allergies to
animal dander. I don‘t 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.
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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: p. 460
OBJ: 8
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 child‘s sense of industry.
DIF: Cognitive Level: Application
REF: p. 445
OBJ: 3
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. 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: pp. 450-451 OBJ: 4
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.
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DIF: Cognitive Level: Application
REF: p. 452
OBJ: 3
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 nurse that her art teacher, a woman, is her hero. What is
the most appropriate interpretation of the girl‘s comment?
The student may be exploring her career options.
The comment is cause for concern about sexual abuse.
The child may have difficulty interacting with her peers.
Hero worship is a normal phenomenon.
a.
b.
c.
d.
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: p. 452| Table 19.3
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: p. 445
OBJ: 3
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 child leads the nurse to determine he has moved from the
mind-set of egocentrism?
“I am a member of the best Cub Scout group in the world.”
“I must do my homework before I can play.”
“My dad can do anything!”
“I‘m sorry. I bet that hurt your feelings.”
a.
b.
c.
d.
ANS: D
The ability to see another‘s point of view indicates moving away from egocentrism into a
more altruistic mind-set.
DIF: Cognitive Level: Analysis
REF: p. 445| Table 19.3
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 can‘t do this!”
What is the most developmentally supportive response from the parent?
a. Ask, “What is it that is so difficult?”
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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: p. 448 | Table 19.2
OBJ: 3
TOP: Industry
KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19. What is best for the nurse to suggest to the parents of an overweight 9-year-old child to help
prevent obesity?
Use whole milk as a between-meal snack because it is more filling than skim milk.
Feed the child before family meal times to monitor intake more closely.
Encourage the child to engage in physical activity for at least an hour a day.
Remove all sweets and junk food from the house.
a.
b.
c.
d.
ANS: C
Regular physical activity reduces weight.
DIF: Cognitive Level: Comprehension
REF: p. 458 | Nursing Tip
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?
Express alarm at the constant aggression.
Voice concern and investigate referral for counseling.
Inquire about what punitive action the parents have taken to stop it.
Offer reassurance that such behavior is normal for 8-year-olds.
a.
b.
c.
d.
ANS: D
Argumentative and competitive behavior is normal in 8-year-olds.
DIF: Cognitive Level: Application
REF: p. 452 | Table 19.3
OBJ: 3
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 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.
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DIF: Cognitive Level: Application
REF: p. 447
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?
Moral development
Social development
Physical development
Cognitive development
a.
b.
c.
d.
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: p. 448
OBJ: 5
TOP: Impact of School Life
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. 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: p. 458 | Nursing Tip
OBJ: 3
TOP: Expression of Feelings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
2. 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.)
Participation in group activity increases.
Egocentricity prevails.
Thinking is logical.
Preference is toward family interaction.
Understand cause and effect.
a.
b.
c.
d.
e.
ANS: A, C, E
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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: p. 445
OBJ: 2
TOP: Personality Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3. 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: p. 450 | Health Promotion | p. 455 | Table 19.3
OBJ: 6
TOP: Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. 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 ownership may provide to their child.
What benefits of pet 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: pp. 458-460 OBJ: 8
TOP: Pet Ownership
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
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1. The nurse advises the parents of a 6-year-old child to try and ensure at least
sleep daily for the child.
ANS:
11
The 6-year-old school-age child needs at least 11 hours of sleep.
DIF: Cognitive Level: Comprehension
REF: p. 451
OBJ: 3
TOP: Sleep Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. 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.
DIF: Cognitive Level: Knowledge
REF: p. 446
OBJ: 3
TOP: Eruption of Permanent Teeth
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
hours of
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Chapter 20: The Adolescent
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is assessing a 13-year-old boy. Which physical change indicates that male puberty
has begun?
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: p. 465
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 nurse‘s
most informative response?
“It may seem that way because girls have a growth spurt 2 years earlier than boys.”
“Perhaps your parents are not exceptionally tall.”
“Boys usually experience a growth spurt 1 year earlier than girls.”
“You may feel short, but you are actually average height for your age.”
a.
b.
c.
d.
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: p. 465
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?
She is bored.
She is not getting enough rest.
She is trying to block out stress and anxiety.
She is mentally preparing for real situations.
a.
b.
c.
d.
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: pp. 471-472 OBJ: 5
TOP: Development—Daydreams
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. Which is the top cause of
accidental deaths during adolescence?
Firearms
Automobiles
Drowning
Diving injuries
a.
b.
c.
d.
ANS: B
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The chief safety hazard for the adolescent is automobiles.
DIF: Cognitive Level: Knowledge
REF: p. 477
OBJ: 11 | 14
TOP: Safety
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. A 16-year-old boy excitedly tells his parents that he was offered a part-time job. Which
response represents an effective problem-solving approach for his parents?
“Your studies are too important for you to have a part-time job.”
“When we went to high school, academics were the adolescent‘s priority.”
“We want you to put your earnings in a savings account.”
“How do you think you will manage your school work and a job?”
a.
b.
c.
d.
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: p. 475 | Health Promotion Box
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 sense of initiative
A sense of industry
A sense of identity
A sense of involvement
a.
b.
c.
d.
ANS: C
Psychosocial milestones that must be accomplished during adolescence include the five
Is—image of self, identity, independence, interpersonal relationships, and intellectual
maturity.
DIF: Cognitive Level: Knowledge
REF: p. 462
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: p. 467
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. What
is the target age the nurse should choose for this program?
10 years
12 years
14 years
16 years
a.
b.
c.
d.
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: p. 465
OBJ: 4
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 adult
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: p. 471
OBJ: 14
TOP: Development—Responsibility
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?
Green, leafy vegetables
Citrus fruits
Nuts
Enriched breads
a.
b.
c.
d.
ANS: C
Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources
include nuts, legumes, and wheat germ.
DIF: Cognitive Level: Comprehension
REF: p. 476
OBJ: 12
TOP: Nutrition
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11. An adolescent‘s parent comments, “My son seems so preoccupied with his appearance these
days. Is this normal?” What is the nurse‘s best response?
“It is his attempt to express his individualism.”
“His preoccupation with his looks is quite normal.”
“He is probably troubled with his physical changes.”
“This shows that he has a positive self-image.”
a.
b.
c.
d.
ANS: B
Preoccupation with self-image is normal and accounts for the constant primping of
adolescents.
DIF: Cognitive Level: Application
REF: p. 466 | Table 20.1
OBJ: 13 | 4
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
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d. A bagel and skim milk
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: p. 476
OBJ: 12
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 girl‘s questions about menstruation, the nurse must
consider cognitive development. What is developed during adolescence according to Piaget?
The ability to view a situation from multiple perspectives
The ability to focus more on the past than present situations
The ability to exercise concrete reasoning
The ability to consider hypothetical situations
a.
b.
c.
d.
ANS: D
According to Piaget, in the formal operations stage adolescents have the ability to think
abstractly.
DIF: Cognitive Level: Comprehension
REF: p. 462 |Box 20.1
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 girl‘s statement as
characteristic of what time period?
a. Early adolescence
b. Middle adolescence
c. Late adolescence
d. The entire adolescent period
ANS: A
Cliques of unisex friends, having a best friend, and hero worship are characteristics of the
early adolescent.
DIF: Cognitive Level: Comprehension
REF: p. 470
OBJ: 9
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 can‘t do anything without checking with his friends first. My opinion doesn‘t 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 adolescent‘s exaggerated conformity is
necessary for moving away from dependence and obtaining approval from persons outside the
nuclear family.
DIF: Cognitive Level: Comprehension
REF: p. 470
OBJ: 9
TOP: Peer Relationships
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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16. What does an adolescent‘s peer group serve as related to development?
a. Social outlet
b. Association to blur personal identity
c. Platform for “group think”
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: p. 474
OBJ: 9
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 Freud‘s theory?
a. Conceptual
b. Genital
c. Glandular
d. Pubertal
ANS: B
Freud describes the adolescent period as genital.
DIF: Cognitive Level: Knowledge
REF: p. 463 | Box 20.1
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?
Nonindicative of potential substance abuse
Normal experimentation of the adolescent
Need to schedule another PACE interview in 3 months
Indication for referral for counseling
a.
b.
c.
d.
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: p. 479
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: p. 463
OBJ: 14
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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 parent‘s feeling to an
adolescent. What is the most appropriate example of an “I” message?
“I feel frightened when you stay out past your curfew.”
“I am your mother, and I insist that you observe your curfew.”
“I am sick and tired of your staying out late.”
“I expect you to show me proper respect.”
a.
b.
c.
d.
ANS: A
This is the only statement that associates the parent‘s feelings about the adolescent behavior
that is not aggressive or accusatory.
DIF: Cognitive Level: Analysis
REF: p. 475 | Health Promotion Box
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?
“Your hormone levels may be irregular.”
“Could you be pregnant?”
“Age of first menstrual cycle varies.”
“Do not worry about it.”
a.
b.
c.
d.
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: p. 465
OBJ: 10
TOP: Menstrual Cycle
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22. The nurse is documenting the pediatrician‘s assessment of a female patient. When assessing
Tanner‘s 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
d. Stage 4
ANS: A
According to Tanner‘s Stages of Sexual Maturity, Stage 1 (preadolescent) is elevation of
papilla only.
DIF: Cognitive Level: Application
REF: p. 466 | Box 20.2
OBJ: 6
TOP: Breast Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
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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: p. 476
OBJ: 13
TOP: Sport Guidelines
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
1. Restlessness in adolescence is most likely attributed to which changes? (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: p. 462
OBJ: 7
TOP: Sources of Stress for the Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2. 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.)
Pancakes and syrup
Coffee and chocolate-covered donuts
Bacon and fried eggs
Whole grain cereal and yogurt
Oatmeal and sliced apples
a.
b.
c.
d.
e.
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: p. 472
OBJ: 12
TOP: Nutrition
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse considers what “rites of passage” valued by the adolescent in American society?
(Select all that apply.)
Attaining legal drinking age
Selection of a career
Religious affiliation
Obtaining a driver‘s license
High school graduation
a.
b.
c.
d.
e.
ANS: A, D, E
Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age,
driver‘s 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: p. 478 | Nursing Tip
OBJ: 9
TOP: Rites of Passage
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4. 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 immediately seek a support group for parents of gays.
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: p. 473
OBJ: 11
TOP: Homosexuality
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. 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? (Select all that apply.)
a.
b.
c.
d.
e.
Developing intimacy
Maintaining dependence on parents
Searching for identity
Adjusting to body changes
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: p. 462
OBJ: 3
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TOP: Challenges
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
1. The nurse stresses the need for using a sunscreen with a sun protection factor (SPF) of at least
.
ANS:
30
A sunscreen with an SPF of at least 30 is recommended to block sun rays that cause cancer.
DIF: Cognitive Level: Knowledge
REF: p. 477
OBJ: 14
TOP: Sunscreen
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
Chapter 21: The Child’s Experience of Hospitalization
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. Which child would have the most difficulty in coping with separation from parents because of
hospitalization?
3-month-old child
16-month-old child
4-year-old child
7-year-old child
a.
b.
c.
d.
ANS: B
Separation anxiety occurs after age 6 months and is most pronounced in the toddler.
DIF: Cognitive Level: Comprehension
REF: p. 485
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?
The toddler feels abandoned by his mother.
The child still has not adjusted to his hospitalization.
The child is not separated from his mother often.
There is a poor mother–child bond.
a.
b.
c.
d.
ANS: A
Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization
are obvious.
DIF: Cognitive Level: Analysis
REF: p. 485
OBJ: 3
TOP: Separation Anxiety
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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3. Which statement best corresponds to a preschooler‘s 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: p. 496
OBJ: 5 | 9 | 10
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?
Protest
Despair
Denial
Attachment
a.
b.
c.
d.
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: p. 486
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 adolescent 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 adolescent 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: p. 497
OBJ: 9 | 11
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.
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d. The preschooler needs to visit his infant sister to reassure himself that she is all
right.
ANS: D
Siblings are affected by a child‘s hospitalization. Their ability to cope is influenced by their
age, experience, and intactness of the family.
DIF: Cognitive Level: Application
REF: p. 491
OBJ: 8
TOP: Siblings—Parents‘ 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: p. 495
OBJ: 1 | 10
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?
Attempting to re-establish rapport
Providing a way for the child to express his feelings
Encouraging quiet play
Distracting the child from thinking about the pain
a.
b.
c.
d.
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: p. 497
OBJ: 9 | 11
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 5-year-old child for surgery and hospitalization?”
a. “As soon as the surgery is scheduled”
b. “About 2 weeks before surgery”
c. “About 4 days before surgery”
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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: p. 492
OBJ: 10
TOP: The Nurse‘s Role in Hospital Admission—Preparing the Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
10. The mother of a 3-year-old child 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 nurse‘s 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.”
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: p. 496
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 girl‘s 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: p. 497
OBJ: 11
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 nurse‘s most appropriate response to this
mother?
a. “Would you like to do all of your child‘s care?”
b. “I‘m doing the very best job that I can with your child.”
c. “Why don‘t you go have a cup of coffee? You are going to be exhausted if you
don‘t take a break.”
d. “I‘d love for you to share with me some of the special things you do for your
child.”
ANS: D
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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: p. 498
OBJ: 4
TOP: The Parents‘ ReactionKEY:
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 nurse‘s 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: p. 486
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?
Eye-to-eye contact is considered disrespectful.
Touching the child‘s head means the nurse is superior.
Smiling is inappropriate in a serious situation.
Staring is a sign of the nurse‘s rudeness.
a.
b.
c.
d.
ANS: C
In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.
DIF: Cognitive Level: Comprehension
REF: p. 490
OBJ: 4
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 child‘s parents during the
admission process?
Direct the parents to undress the child.
Answer questions in a calm and matter-of-fact way.
Perform assessments and ask questions as quickly as possible.
Express concern about the seriousness of the child‘s condition.
a.
b.
c.
d.
ANS: B
The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless
of the child‘s condition.
DIF: Cognitive Level: Application
REF: p. 492
TOP: Nurse‘s Role in Hospital Admission
OBJ: 4
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KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
16. When a 2-year-old child 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 child‘s 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: p. 495
OBJ: 5
TOP: The Hospitalized Toddler
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
17. A 4-year-old child 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 child is afraid of bodily harm, particularly invasive procedures.
DIF: Cognitive Level: Comprehension
REF: p. 496
OBJ: 5
TOP: The Hospitalized Preschooler
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
18. What statement by the parent of a hospitalized toddler leads the nurse to determine the parent
understands a hospitalized toddler‘s need for transitional objects?
“This stuffed animal makes him feel secure.”
“He insisted on bringing this dirty old blanket with him.”
“I‘m going to buy him a big stuffed animal from the gift shop.”
“I‘d like to get him some toys from the playroom.”
a.
b.
c.
d.
ANS: A
The use of a transitional object such as a blanket or a favorite toy promotes security.
DIF: Cognitive Level: Application
REF: p. 494
OBJ: 5
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
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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: p. 496
OBJ: 10
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
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?
It is specifically designed for children.
It has a rapid onset.
It is nonaddicting.
It has a long duration.
a.
b.
c.
d.
ANS: B
Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.
DIF: Cognitive Level: Knowledge
REF: p. 488
OBJ: 6
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?
Clinical pathway
Comprehensive nursing care plan
Holistic care approach
Incorporated cost analysis
a.
b.
c.
d.
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: p. 493
OBJ: 9
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 danger of her 2-year-old child becoming addicted to the
opioid pain reliever. What is the nurse‘s most helpful response?
“Although this drug is addictive, the doctor monitors the dose very carefully.”
“Don‘t worry. Addicted children are very easy to wean off the drug.”
“Addiction is rare in children when opiates are given for pain.”
“Addictive behaviors are easy to assess. The drug will be stopped if that happens.”
a.
b.
c.
d.
ANS: C
Addiction is rare in children.
DIF: Cognitive Level: Comprehension
REF: p. 488
OBJ: 6
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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?
Involve the parents.
Provide a simple explanation to the child.
Let the child examine the equipment.
Suggest coping techniques.
a.
b.
c.
d.
ANS: A
It is appropriate to involve the parents when performing a procedure on an infant. Providing 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: p. 484
OBJ: 4
TOP: Age-Appropriate Interventions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. The pediatric nurse is caring for a child that weighs 15 kg 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: p. 488
OBJ: 6
TOP: Age-Appropriate Interventions
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
1. What will the nurse include when documenting the discharge of a pediatric patient? (Select all
that apply.)
Time of discharge
Adult(s) accompanying the child and the relationship to the child
Condition of the child
Method of transportation
Instructions that were given to physician
a.
b.
c.
d.
e.
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 the 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: p. 498 | Legal and Ethical Considerations Box
OBJ: 12
TOP: Discharge Documentation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
2. The nurse suggests to parents that they use the outpatient surgical center for their child‘s
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 care–associated 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: pp. 483-484 OBJ: 2
TOP: Outpatient Facilities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3. 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
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: p. 485
OBJ: 5
TOP: Basic Fear
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
4. 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. Child‘s nickname
ANS: A, B, E
The developmental history has information about the child and the child‘s 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
TOP: Developmental History
REF: p. 492
OBJ: N/A
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
5. 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.)
Model desired behavior.
Instruct patient not to yell.
Use distractions.
Explain the procedure in detail.
Encourage the child to ask questions.
a.
b.
c.
d.
e.
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: p. 484
OBJ: N/A
TOP: Promoting a Positive Experience
KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6. 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.)
Nurses wearing all white
Formal atmosphere
Availability of a playroom
Dim lighting
Colored bedding
a.
b.
c.
d.
e.
ANS: C, E
The children‘s 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
child‘s 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: pp. 484-485 OBJ: 2
TOP: Health Care Delivery Settings/Pediatric Unit
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
Chapter 22: Health Care Adaptations for the Child and Family
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
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1. What is the best pulse location for the nurse to use when assessing the pulse rate on a
12-month-old infant?
Brachial
Apical
Radial
Femoral
a.
b.
c.
d.
ANS: B
Apical pulses are advised for children under age 5 years.
DIF: Cognitive Level: Knowledge
REF: p. 505
OBJ: 10
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 child‘s 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 child‘s 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: pp. 500-501 OBJ: 2
TOP: ID Bracelets KEY: Nursing Process Step: Implementation
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. “I‘ll 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: p. 511
OBJ: 7
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.
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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: p. 516 | Skill 22.6
OBJ: 9
TOP: Administering Oral Medications
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. A parent tells the nurse, “I‘m 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 infant‘s mouth.
d. Administer the medication with a dropper onto the back of the infant‘s 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: p. 515
OBJ: 9
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?
Up and back
Down and back
Up and out
Down and out
a.
b.
c.
d.
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: p. 517 | Skill 22.8
OBJ: 9
TOP: Administering Ear Drops
KEY: Nursing Process Step: Implementation
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.
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DIF: Cognitive Level: Knowledge
REF: p. 508
OBJ: 10
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 Fowler‘s position or on the
right side to promote gastric emptying after a gastrostomy tube feeding.
DIF: Cognitive Level: Application
REF: p. 529 | Skill 22.10
OBJ: 14
TOP: Enteral Feedings
KEY: Nursing Process Step: Implementation
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: p. 502
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: p. 519
TOP: Administering Parenteral Medications
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
OBJ: 12
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?
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a.
b.
c.
d.
1.25
1.4
1.6
1.8
ANS: B
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: p. 517 | Medication Safety Alert| p. 525
OBJ: 11
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: p. 530
OBJ: 16
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: p. 534
TOP: Management of Airway Obstruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
OBJ: 2
14. A 4-year-old child asks tearfully if the IM injection will hurt. What is the nurse‘s 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
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Truthful answers will give a child a realistic expectation and help establish trust in the nurse.
DIF: Cognitive Level: Application
REF: p. 518
OBJ: 11
TOP: Preparation for an IM Injection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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: p. 517
OBJ: 11
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 infant‘s 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: p. 514
TOP: Physiological Responses to Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
OBJ: 4
17. What intervention should the nurse implement after topical administration of hydrocortisone
cream to the buttocks and abdomen of an infant?
Diaper the infant snugly with a disposable diaper.
Cover the area with a transparent dressing.
Apply a cloth diaper.
Place the infant on a plastic pad, undiapered.
a.
b.
c.
d.
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: p. 514
OBJ: 2
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?
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a.
b.
c.
d.
The blanket is not tucked into the mattress.
Diapers and wipes are stacked at the foot of the crib.
The crib side is locked in the up position.
Pillows are stacked on the bedside table.
ANS: B
Disposable diapers and supplies must be kept out of the infant‘s reach to prevent accidental
suffocation.
DIF: Cognitive Level: Analysis
REF: p. 501
OBJ: 2
TOP: Essential Safety Measures
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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?
“On your stomach with your head turned to the side.”
“On your side, keeping the legs bent and the head arched back.”
“On your back with your legs extended straight out.”
“On your side with the knees bent and the head close to the knees.”
a.
b.
c.
d.
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: p. 513
OBJ: 8
TOP: Collecting Specimens—Lumbar 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 child‘s daily urinary
output to be?
a. 400 to 500 mL
b. 500 to 600 mL
c. 600 to 720 mL
d. 700 to 1000 mL
ANS: C
The average daily excretion of urine for a 4-year-old child is 600 to 720 mL.
DIF: Cognitive Level: Knowledge
REF: p. 512 | Table 22.1
OBJ: 7
TOP: Collecting Specimens—Urine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. An infant‘s dry diaper weighs 2.5 g. The wet diaper weighs 47 g. How would the nurse record
the infant‘s urine output?
a. 47 mL
b. 44.5 mL
c. 43.5 mL
d. 40.5 mL
ANS: B
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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 g = 44.5 mL of
urine.
DIF: Cognitive Level: Analysis
REF: p. 528 | Nursing Tip
OBJ: 7
TOP: Collecting Specimens—Urine 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 child 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: p. 528 | Table 22.5
OBJ: 2
TOP: Food/Drug Interactions
KEY: Nursing Process Step: Implementation
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?
Toddler with an axillary temperature of 99°F
School-age child with widening pulse pressure
Infant pulse rate of 100 beats/minute
Adolescent with a respiratory rate of 28 breaths/minute
a.
b.
c.
d.
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: p. 504
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?
Left side-lying
Supine
Prone
Semi-Fowler‘s
a.
b.
c.
d.
ANS: B
The adolescent may avoid post–lumbar puncture headache by lying flat for some time.
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DIF: Cognitive Level: Application
REF: p. 514
OBJ: 8
TOP: Lumbar Puncture
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
1. 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: p. 500
OBJ: 4
TOP: Informed Consent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
2. Which specific drug(s) should be checked with a second licensed nurse prior to
administration? (Select all that apply.)
Insulin
Digoxin
Vasodilators
Calcium salts
Anticoagulants
a.
b.
c.
d.
e.
ANS: A, B, D, E
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: p. 521 | Medication Safety Alert
OBJ: 2
TOP: Drug Administration
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. 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.)
Assess rectal temperature every 4 hours.
Administer acetaminophen as ordered.
Assess skin turgor.
Restrict fluids.
Assess level of consciousness.
a.
b.
c.
d.
e.
ANS: B, C, E
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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: p. 508
OBJ: 6
TOP: Fever
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. What should the nurse assess to determine the method of transportation for a pediatric patient?
(Select all that apply.)
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: p. 502
OBJ: 3
TOP: Modes of Transportation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
1. 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
Per the safe drug dose calculation, 16 mL is the correct dose to give.
DIF: Cognitive Level: Analysis
REF: p. 525
OBJ: 13
TOP: Pediatric Dose Calculation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. 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.
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DIF: Cognitive Level: Comprehension
REF: p. 515 | Skill 22.7
OBJ: N/A
TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
Chapter 23: The Child with a Sensory or Neurological Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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 infant‘s Eustachian tubes are short, wide, and straight, allowing microorganisms easy
access to the middle ear.
DIF: Cognitive Level: Knowledge
REF: p. 539
OBJ: 2
TOP: Otitis Media KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. What statement by a patient‘s mother leads the nurse to determine she understands
instructions about administering an oral antibiotic for otitis media?
“I will continue using the medication until symptoms are relieved.”
“I will share the medicine with siblings if their symptoms are the same.”
“I will give the medication with a glass of milk.”
“I will administer prescribed doses until all the medication is used.”
a.
b.
c.
d.
ANS: D
Antibiotic therapy for otitis media is continued until the prescribed amount has been
completed, even if symptoms are alleviated.
DIF: Cognitive Level: Application
REF: p. 542 | Nursing Tip
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 (startle reaction) 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 24 months should undergo a complete
physical examination.
DIF: Cognitive Level: Analysis
REF: pp. 540-541 OBJ: 3
TOP: Hearing Impairment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing
impairment?
Use gestures and signs as much as possible.
Let the child‘s parents communicate for her.
Face the child and speak clearly in short sentences.
Recognize that the child‘s ability to communicate will be on a 6-year-old child‘s
level.
a.
b.
c.
d.
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
TOP: Hearing Impairment
MSC: NCLEX: Physiological Integrity
REF: p. 543
OBJ: 3
KEY: Nursing Process Step: Implementation
5. What would the nurse include when planning postoperative teaching for a child who has had a
tympanostomy with insertion of tubes?
Keeping the infant flat after feeding
Giving over-the-counter decongestants
Avoiding getting water in the ears
Cleaning the ear canal with cotton-tipped applicators
a.
b.
c.
d.
ANS: C
After a tympanostomy, care should be taken to avoid getting water in the ears.
DIF: Cognitive Level: Comprehension
REF: p. 542
TOP: Postoperative Care of Tympanostomy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
OBJ: 2
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.
DIF: Cognitive Level: Analysis
REF: p. 545
OBJ: 5
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
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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: p. 545
OBJ: 4
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: p. 547
OBJ: N/A
TOP: Hyphema
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. The nurse is planning to teach parents about prevention of Reye‘s 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 Reye‘s syndrome.
c. Avoid giving salicylate-containing medications to a child who has viral symptoms.
d. Get the child tested for Reye‘s syndrome if the child exhibits fever, vomiting, and
lethargy.
ANS: C
Prevention of Reye‘s syndrome includes educating parents not to give aspirin-containing
medication to children with viral symptoms.
DIF: Cognitive Level: Application
REF: p. 550
OBJ: 10
TOP: Reye‘s 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 child with viral influenza to suspect
the development of Reye‘s syndrome?
a. Respirations drop from 18 to 14 breaths/minute
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 Reye‘s 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
TOP: Reye‘s Syndrome
REF: p. 550
OBJ: 10
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11. What does the nurse explain 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: p. 553
OBJ: 13
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: p. 555 | Table 23.2
OBJ: 13
TOP: Epilepsy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13. An adolescent has just had a generalized seizure and collapsed in the school nurse‘s office.
When should the nurse should call 911?
The seizure lasts more than 5 minutes.
The child is sleepy and lethargic after the seizure.
The child vomited at the onset of the seizure.
The child is confused and has slurred speech after the seizure.
a.
b.
c.
d.
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: p. 555 | Table 23.2
OBJ: 13
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?
Assist the child to bed and then go for help.
Move objects out of the child‘s immediate area.
Stick a padded tongue blade between the child‘s teeth.
Manually restrain the child.
a.
b.
c.
d.
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ANS: B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child
from injury.
DIF: Cognitive Level: Application
REF: p. 555 | Table 23.2
OBJ: 13
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 tonic-clonic seizure?
Restlessness
Sleepiness
Nausea
Anxiety
a.
b.
c.
d.
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: p. 555 | Table 23.2
OBJ: 13 | 15
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)?
The medication should be given on an empty stomach.
Insomnia can be a significant side effect.
Gums should be massaged regularly to prevent hyperplasia.
Blood pressure should be closely monitored.
a.
b.
c.
d.
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: p. 557 | Table 23.3 | Figure 23.10
OBJ: 13
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 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
TOP: Cerebral Palsy
REF: p. 559
OBJ: 14
KEY: Nursing Process Step: Data Collection
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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: p. 552
OBJ: 11
TOP: Meningitis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
19. The nurse observes a child‘s position is supine with his arms and legs rigidly extended and the
hands pronated. How does the nurse identify this posture?
Correct anatomical position
Decorticate
Decerebrate
Opisthotonos
a.
b.
c.
d.
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: p. 565 | Figure 23.13
OBJ: 17
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 eyedrops 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: p. 547
OBJ: N/A
TOP: Conjunctivitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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?
Sleepy but easily arousable
Complaining of a stiff neck
Cannot remember what happened to him
Pupils react sluggishly to light
a.
b.
c.
d.
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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: p. 564
OBJ: 15
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. Reye‘s 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: p. 552
OBJ: N/A
TOP: Brain Tumor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23.
The nurse urges the mother of a 6-month-old child 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: p. 551
OBJ: 11
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 child with a head injury. Which assessment would lead
the nurse to report the probability of increasing intracranial pressure (ICP)?
Temperature increase from 37.2C (99F) to 37.7C (100F)
Increase in blood pressure with an attendant decrease in pulse
Increase in respirations
Equilateral pupils
a.
b.
c.
d.
ANS: B
Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal
pupils are indicators of ICP.
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DIF: Cognitive Level: Comprehension
REF: p. 553|Figure 23.9
OBJ: 12
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?
Patching the unaffected eye
Corrective lenses
Laser treatment
Surgery
a.
b.
c.
d.
ANS: B
In nonparalytic strabismus, the refractory error is usually corrected with eyeglasses.
DIF: Cognitive Level: Comprehension
REF: p. 546
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 statement by the
parents alerts the nurse 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: p. 563 |Nursing Tip
OBJ: 16
TOP: Cognitive Impairment
KEY: Nursing Process Step: Implementation
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?
Using ear plugs during takeoff
Omitting the meal just before takeoff
Letting the infant nurse during descent
Applying ear drops before takeoff
a.
b.
c.
d.
ANS: C
Encouraging an infant to swallow reduces the pressure in the ears during descent.
DIF: Cognitive Level: Comprehension
REF: p. 543
OBJ: 1
TOP: Barotrauma KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
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1. Which assessments would cause the pediatric nurse to suspect the probability of an ear
infection in a 6-month-old child? (Select all that apply.)
Hypersensitivity to noise
Irritability
Ecchymotic ear canal
Rolls head from side to side
Temperature of 39.4C (103F)
a.
b.
c.
d.
e.
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.
DIF: Cognitive Level: Comprehension
REF: p. 541 | Nursing Tip
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
2. Which aspect(s) of a child‘s development does the nurse caution parents that hearing
impairment can affect? (Select all that apply.)
Speech clarity
Language development
Immunity to disease
Personality development
Academic achievement
a.
b.
c.
d.
e.
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: p. 542
OBJ: 3
TOP: Hearing Impairment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What intervention(s) would the nurse caring for a child with infectious meningitis include?
(Select all that apply.)
Isolation precautions
Provision of brightly lit room
Observation for increasing intracranial pressure
Preparation for spinal tap
Seizure precautions
a.
b.
c.
d.
e.
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: pp. 551-552 OBJ: 11
TOP: Nursing Care of Child with Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. What will the nurse include when documenting a grand mal seizure? (Select all that apply.)
a. Presence of incontinence
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b.
c.
d.
e.
Current dose of antispasmodic medication
Activity level prior to and following seizure
Level of consciousness following seizure
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: p. 554
OBJ: 13
TOP: Documentation of Seizure
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. 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.)
Encourage books with large type.
Words in books should be closely spaced.
Provide adequate lighting without glare.
Be sure desks and chairs are adequate height.
Instruct child to squint when reading.
a.
b.
c.
d.
e.
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: p. 546
OBJ: 6
TOP: Eyestrain
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
6. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be
implemented? (Select all that apply.)
Parental education regarding prevention
Respiratory support
Cardiovascular support
Controlled rewarming
Adequate cerebral oxygenation
a.
b.
c.
d.
e.
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: p. 568
OBJ: 15
TOP: Near-drowning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 24: The Child with a Musculoskeletal Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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MULTIPLE CHOICE
1. What would the nurse include in planning teaching to parents of a child with
Legg-Calvé-Perthes disease about the long-term effects of this disease?
There are no long-term effects.
The disease is self-limited and requires no long-term treatment.
Degenerative arthritis may develop later in life.
There is risk of osteogenic sarcoma in adulthood.
a.
b.
c.
d.
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: p. 584
OBJ: 11
TOP: Legg-Calvé-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 Buck skin traction implement?
a. Position in high Fowler‘s position.
b. Assist the child to be pulled up in bed.
c. Keep child‘s heel on the bed surface.
d. Maintain child‘s feet against the foot of the bed.
ANS: B
Buck traction is a type of skin traction that relies on the child‘s 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.
DIF: Cognitive Level: Application
REF: p. 577
OBJ: 6
TOP: Buck‘s 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 Buck‘s 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: p. 579 | Nursing Tip
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 Ewing‘s sarcoma. Which statement if made by
the nurse indicates correct understanding of this disease?
“Amputation is the accepted treatment.”
“The disease is sensitive to radiation and chemotherapy.”
“Metastasis is rare.”
“The disease is more prevalent among toddlers and preschoolers.”
a.
b.
c.
d.
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ANS: B
Ewing‘s 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: p. 585
OBJ: N/A
TOP: Ewing‘s 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 Duchenne‘s muscular
dystrophy document?
Ambulates by holding onto furniture.
Exhibits atrophy of the calf muscles.
Falls frequently and is clumsy.
Has delayed fine-motor development.
a.
b.
c.
d.
ANS: C
Frequent falling and clumsiness are clinical manifestations of Duchenne‘s muscular
dystrophy.
DIF: Cognitive Level: Knowledge
REF: p. 584
OBJ: 10
TOP: Duchenne‘s 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 child‘s 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: pp. 588-586 OBJ: 12
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?
“Apply warm compresses to the ankle for the first 24 hours.”
“Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off.”
“Wrap the ankle in an Ace bandage for support.”
“Keep the leg elevated when sitting.”
a.
b.
c.
d.
ANS: A
Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries
are rest, ice, compression, and elevation.
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DIF: Cognitive Level: Application
REF: p. 575 | Memory Jogger
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 Buck, 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.
DIF: Cognitive Level: Comprehension
REF: p. 576
OBJ: 6
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 Bryant‘s traction. How long does it take
for the toe to regain color if adequate perfusion is assessed?
3 seconds
4 seconds
5 seconds
6 seconds
a.
b.
c.
d.
ANS: A
Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.
DIF: Cognitive Level: Comprehension
REF: p. 579 | Skill 24.1
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?
“Pressure of inelastic bone”
“Purulent drainage in the bone marrow”
“The cast applied on the extremity”
“Circulatory congestion of the skin”
a.
b.
c.
d.
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: p. 583
OBJ: N/A
TOP: Osteomyelitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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: p. 583
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?
Skin that‘s warm to the touch
Capillary refill less than 3 seconds
Ability to wiggle toes
Bluish coloration of skin
a.
b.
c.
d.
ANS: D
Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.
DIF: Cognitive Level: Application
REF: p. 578
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?
Juvenile rheumatoid arthritis
Poor posture
Heredity
Myelomeningocele
a.
b.
c.
d.
ANS: B
Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.
DIF: Cognitive Level: Comprehension
REF: p. 586
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 child‘s 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 child‘s shoulders and hips while fully clothed.
ANS: A
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The nurse looks at the back as the child bends forward for general body alignment and
asymmetry.
DIF: Cognitive Level: Application
REF: p. 588
OBJ: 13
TOP: Scoliosis
KEY: Nursing Process Step: Data Collection
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
Bryant‘s traction?
Neurovascular checks are done frequently.
Bandages are wrapped tightly.
The child is restrained from rolling over.
The child‘s buttocks are resting on the bed.
a.
b.
c.
d.
ANS: A
The nurse caring for a child in traction must be alert for Volkmann‘s ischemia, which occurs
when circulation is obstructed.
DIF: Cognitive Level: Application
REF: p. 578
OBJ: 7 | 8
TOP: Traction: Volkmann‘s 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?
Wearing splints at night to prevent extension contractures
Applying moist heat packs upon awakening
Taking a warm tub bath the evening before
Sleeping with two pillows under the head
a.
b.
c.
d.
ANS: B
Application of moist heat, with a compress or by tub bath upon awakening in the morning,
will help to lessen stiffness.
DIF: Cognitive Level: Application
REF: p. 586
OBJ: 12
TOP: Juvenile Rheumatoid Arthritis
KEY: Nursing Process Step: Implementation
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: p. 587
OBJ: 13
TOP: Scoliosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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18. Which observation is most likely to cause the nurse to consider the possibility of child abuse
when a mother says that her young child fell down the basement stairs?
Red, green, and yellow bruises on his body.
Bruises are dispersed on his head, arms, and legs.
A broken arm last year, and the child being described as accident-prone.
The mother is very anxious for her son to get medical attention.
a.
b.
c.
d.
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
caretaker‘s explanation of what happened.
DIF: Cognitive Level: Analysis
REF: p. 592 | Safety Alert
OBJ: 15
TOP: Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention 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: p. 582 | NCP 24.1
OBJ: 7 | 8
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?
Has inward-turned knees while standing.
Walks on the toes.
Appears to have flat feet.
Swings his arms when walking.
a.
b.
c.
d.
ANS: B
Toe walking after 3 years of age may indicate a muscle problem.
DIF: Cognitive Level: Analysis
REF: p. 573
OBJ: 3
TOP: Assessment of the Musculoskeletal System
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21. Why does a child‘s fracture heal more rapidly than the adult‘s?
a. A child‘s bones are less porous than adult bone.
b. A child‘s bones are covered by a thicker periosteum.
c. A child‘s bones are not affected by bone overgrowth.
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d. A child‘s bones have faster callus formation.
ANS: D
Callus forms more rapidly in the child than the adult.
DIF: Cognitive Level: Knowledge
REF: p. 573
OBJ: 2
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 Buck traction, the nurse makes all of the following
observations. Which observation requires a nursing intervention?
Child‘s heels are placed firmly against the foot of the bed.
Head of bed is elevated 20 degrees.
Weights are hanging freely.
Ropes are on pulleys.
a.
b.
c.
d.
ANS: A
Buck 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: p. 576
OBJ: 7 | 8
TOP: Buck‘s Traction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
23. Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old
to be?
2 days
4 days
6 days
8 days
a.
b.
c.
d.
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: p. 592 | Safety Alert
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?
Stress fracture
Compound fracture
Spiral fracture
Greenstick fracture
a.
b.
c.
d.
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: p. 575 | Safety Alert
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OBJ: 5
TOP: Fractures/Child Abuse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25. 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: p. 590
OBJ: 14
TOP: Child Abuse Triggers
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
26. Which assessment performed by a nursing student performing a neurovascular check alerts
the instructor that further education is necessary?
Pulses
Capillary refill
Movement
Pupils
a.
b.
c.
d.
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: p. 579 | Skill 24.1 | Safety Alert
OBJ: 7
TOP: Neurovascular Assessment
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. 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: p. 590 | Health Promotion Box
OBJ: 15
TOP: Child Abuse Triggers
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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2. 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: pp. 575-579 OBJ: 7
TOP: Traction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. 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.)
Pulse is equal to uncasted limb.
Patient is aware of touch and warm and cold application.
Limb is cool to the touch.
Capillary refill is 5 seconds.
Distal limb can flex and extend.
a.
b.
c.
d.
e.
ANS: C, D
The limb should be warm, and capillary refill should be less than 3 seconds.
DIF: Cognitive Level: Comprehension
REF: p. 579 | Skill 24.1
OBJ: 7
TOP: Neurovascular Assessment
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. 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 child‘s skeletal system has lower mineral content, greater porosity, open epiphyses,
greater bone strength, and a thicker periosteum.
DIF: Cognitive Level: Comprehension
REF: pp. 572-573 OBJ: 2
TOP: Skeletal Differences
KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse explains that Bryant‘s traction is reserved for children who weigh less than
pounds.
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ANS:
30
Bryant‘s 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.
DIF: Cognitive Level: Knowledge
REF: p. 575
OBJ: 8
TOP: Bryant‘s Traction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
Chapter 25: The Child with a Respiratory Disorder
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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?
Acetaminophen and plenty of fluids
Oral penicillin for 10 days
Penicillin until his sore throat is gone
Streptococcus immunization
a.
b.
c.
d.
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: pp. 598-599 OBJ: N/A
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?
Take the child outside in the cool air.
Bring the child directly to the emergency department.
Take the child to the bathroom and turn on a hot shower.
Have the child drink plenty of fluids.
a.
b.
c.
d.
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: p. 600
OBJ: 6
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
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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 child‘s throat could cause frequent swallowing.
DIF: Cognitive Level: Comprehension
REF: p. 606
OBJ: 9
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 popsicle
Chocolate milk
Orange juice
Cola drink
a.
b.
c.
d.
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.
DIF: Cognitive Level: Application
REF: p. 606
OBJ: 9
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 decreases from 40 to 32 breaths/minute
b. Heart rate decreases from 110 to 100 beats/minute
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: p. 602
OBJ: 4 | 6
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?
Fine crackles
Coarse rhonchi
Expiratory wheezing
Decreased breath sounds at lung bases
a.
b.
c.
d.
ANS: C
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The child experiencing an acute asthma attack wheezes as air moves in and out of the
narrowed airways. The expiratory wheeze is most pronounced.
DIF: Cognitive Level: Knowledge
REF: p. 609
OBJ: 13
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?
Offer plenty of fluids, particularly carbonated beverages.
Place the child in a humidified cool mist tent with oxygen.
Administer sedatives as ordered to decrease anxiety.
Position the child with arms resting on the overbed table.
a.
b.
c.
d.
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: p. 612
OBJ: 13
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.
DIF: Cognitive Level: Application
REF: p. 612
OBJ: 13
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 nurse‘s 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
TOP: Cystic Fibrosis
REF: p. 615
OBJ: 14
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10. Which statement indicates that the child‘s parents understand how to perform respiratory
therapy?
“We do her postural drainage before the aerosol therapy.”
“We give her respiratory treatments when she is coughing a lot.”
“We give the aerosol followed by postural drainage before meals.”
“She needs respiratory therapy every day when she has an infection.”
a.
b.
c.
d.
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.
DIF: Cognitive Level: Analysis
REF: p. 615
OBJ: 14
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 child‘s body cannot produce.
DIF: Cognitive Level: Knowledge
REF: p. 618
OBJ: 14
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.
DIF: Cognitive Level: Application
TOP: Nasopharyngitis
MSC: NCLEX: Physiological Integrity
REF: p. 598
OBJ: 2
KEY: Nursing Process Step: Implementation
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
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ANS: A
Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk
stimulates mucus production.
DIF: Cognitive Level: Application
REF: p. 612
OBJ: 13
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: p. 611 | Table 25.3
OBJ: 13
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?
Wrapping the infant snugly for rest periods
Positioning the infant prone for sleep
Sitting the infant up in an infant seat
Placing infants on their backs or sides for sleep
a.
b.
c.
d.
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: p. 622 | Safety Alert
OBJ: 16
TOP: Sudden Infant Death Syndrome
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
16. 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: p. 600
OBJ: 6
TOP: Acute Croup KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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17. 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?
Discoloration of tooth enamel
Halitosis
Irritation of oral membranes
Candidiasis
a.
b.
c.
d.
ANS: D
Inhalant powders can cause candidiasis (yeast) infection of the mouth.
DIF: Cognitive Level: Comprehension
REF: p. 614
OBJ: 13
TOP: Candidiasis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18. The nurse is caring for a 3-year-old child who suffered a smoke inhalation injury. How long is
this patient at the highest risk for pulmonary edema after exposure?
2 hours
4 hours
18 hours
72 hours
a.
b.
c.
d.
ANS: D
Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after
exposure.
DIF: Cognitive Level: Comprehension
REF: p. 605
OBJ: 8
TOP: Smoke Inhalation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19. 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 pancreas 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: p. 621
OBJ: 14
TOP: Cystic Fibrosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20. 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
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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 birth is the best way to prevent
BPD.
DIF: Cognitive Level: Knowledge
REF: p. 622
OBJ: 15
TOP: Bronchopulmonary Dysplasia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
MULTIPLE RESPONSE
1. 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
ANS: A, B, C, E
The allergic salute does not include a productive cough.
DIF: Cognitive Level: Comprehension
REF: p. 607 | Figure 25.4
OBJ: 10
TOP: Allergic Salute
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse would suggest the parents of an asthmatic child to encourage participation in which
sport(s)? (Select all that apply.)
Swimming
Gymnastics
Baseball
Cross-country skiing
Distance running
a.
b.
c.
d.
e.
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: pp. 610-612 OBJ: 12
TOP: Sports Activities Suitable for Asthmatics
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all
that apply.)
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a.
b.
c.
d.
e.
Abdominal distention
Vomiting
Hiccoughing
Jaundice
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: p. 616
OBJ: 1
TOP: Meconium Ileus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. What would the nurse teaching an asthmatic child the technique of pursed-lip breathing
include? (Select all that apply.)
Inhale deeply through nose with mouth closed.
Make exhalation twice as long as inhalation.
Use medicated inhaler prior to perform breathing exercise.
Exhale through mouth as if whistling.
Exhale forcefully.
a.
b.
c.
d.
e.
ANS: A, B, D
The technique requires that breath be inhaled through the nose and exhaled through pursed
lips in a nonforceful manner. The exhalation should be twice as long as the inhalation.
DIF: Cognitive Level: Comprehension
REF: p. 618
OBJ: 13
TOP: Pursed-Lip Breathing
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse
implement? (Select all that apply.)
Maintain strict bed rest.
Consider age.
Assess developmental level.
Implement light play activities.
Provide hypnotic medication as ordered.
a.
b.
c.
d.
e.
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: p. 598
OBJ: 3
TOP: Bed Rest
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
6. 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.
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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.
DIF: Cognitive Level: Comprehension
REF: p. 599
OBJ: 5
TOP: Sinusitis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. 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: p. 601
OBJ: 7
TOP: Epiglottitis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. What will the nurse discourage when providing education to parents of a child with asthma?
(Select all that apply.)
Stuffed toys
Pet ownership
Gymnastics
Basketball
Cotton blankets
a.
b.
c.
d.
e.
ANS: A, D
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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, gymnastics is
usually well tolerated, and cotton blankets are recommended for children with asthma.
DIF: Cognitive Level: Comprehension
REF: p. 609
OBJ: 13
TOP: Asthma
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
COMPLETION
1. 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.
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: p. 602
OBJ: 6
TOP: Respiratory Syncytial Virus (RSV)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 26: The Child with a Cardiovascular Disorder
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: p. 627
OBJ: 4
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
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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: p. 628
OBJ: 4
TOP: Congenital Heart Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What finding would the nurse expect when measuring blood pressure on all four extremities
of a child with coarctation of the aorta?
Blood pressure higher on the right side
Blood pressure higher on the left side
Blood pressure lower in the arms than in the legs
Blood pressure lower in the legs than in the arms
a.
b.
c.
d.
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: p. 629
OBJ: 4
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 nurse‘s best response?
Squatting increases the return of venous blood back to the heart.
Squatting decreases arterial blood flow away from the heart.
Squatting is a common resting position when a child is tachycardic.
Squatting increases the workload of the heart.
a.
b.
c.
d.
ANS: A
The squatting position allows the child to breathe more easily because systemic venous return
is increased.
DIF: Cognitive Level: Comprehension
REF: p. 629
OBJ: 4
TOP: Congenital Heart Disease
KEY: Nursing Process Step: Implementation
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
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When PDA is present, oxygenated blood recycles through the lungs, overburdening the
pulmonary circulation.
DIF: Cognitive Level: Comprehension
REF: p. 629
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?
Counting the apical rate for 30 seconds before administering the medication
Withholding a dose if the apical heart rate is less than 100 beats/minute
Repeating a dose if the child vomits within 30 minutes of the previous dose
Checking respiratory rate and blood pressure before each dose
a.
b.
c.
d.
ANS: B
As a rule, if the pulse rate of an infant is less than 100 beats/minute, the medication is
withheld and the physician is notified.
DIF: Cognitive Level: Application
REF: p. 632
OBJ: 5
TOP: Congestive Heart Failure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. A child develops carditis from rheumatic fever. Which areas of the heart are affected by
carditis?
Coronary arteries
Heart muscle and the mitral valve
Aortic and pulmonic valves
Contractility of the ventricles
a.
b.
c.
d.
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: p. 634
OBJ: 6
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 infant 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: p. 626
OBJ: 3
TOP: Congenital Heart Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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9. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child‘s parent asks
the nurse, “How does Kawasaki disease affect my child‘s heart and blood vessels?” On what
understanding is the nurse‘s 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: p. 638
OBJ: 12
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: p. 630
OBJ: 4
TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Evaluation
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 child‘s
fingertips look like that?” On what understanding does the nurse base a response?
Clubbing occurs as a result of untreated congestive heart failure.
Clubbing occurs as a result of a left-to-right shunting of blood.
Clubbing occurs as a result of decreased cardiac output.
Clubbing occurs as a result of chronic hypoxia.
a.
b.
c.
d.
ANS: D
Clubbing of the fingers develops in response to chronic hypoxia.
DIF: Cognitive Level: Comprehension
REF: p. 632
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
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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: p. 634| Box 26.1
OBJ: 6
TOP: Rheumatic Fever
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?
Restlessness
Decreased respiratory rate
Increased urinary output
Vomiting
a.
b.
c.
d.
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: p. 632
OBJ: 5
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?
The patent ductus arteriosus
A ventricular septal defect
The closure of the foramen ovale
An atrial septal defect
a.
b.
c.
d.
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: p. 630
OBJ: 3
TOP: Hypoplastic Left Heart Syndrome KEY: Nursing Process Step: Planning
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?
Seizure activity
Hypoxia
Sydenham‘s chorea
Decreasing level of consciousness
a.
b.
c.
d.
ANS: C
As the effects of rheumatic fever affect the central nervous system, the child may develop
Sydenham‘s chorea, manifested by involuntary, purposeless movements of the limbs.
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DIF: Cognitive Level: Knowledge
REF: p. 634
OBJ: 6
TOP: Sydenham‘s 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 years to prevent further bouts of rheumatic fever.
DIF: Cognitive Level: Knowledge
REF: p. 635
OBJ: 7
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, and low amount of
cholesterol, and are excreted via the liver. They have no role in the production of steroids.
DIF: Cognitive Level: Knowledge
REF: p. 637
OBJ: 11
TOP: High-Density Lipoproteins
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18. The nurse is planning a hypertension-prevention program. What should be the main focus of
the nurse when presenting information?
Pharmacological treatment
Surgical interventions available
Patient education
Reduction of aerobic exercise
a.
b.
c.
d.
ANS: C
The main focus of a hypertension-prevention program is patient education.
DIF: Cognitive Level: Knowledge
REF: p. 636
OBJ: 10
TOP: Hypertension Prevention
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. 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
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b. Chest x-ray
c. Electrocardiogram
d. Echocardiogram
ANS: D
Echocardiography is a noninvasive procedure that localizes murmurs and determines if the
heart is structurally normal.
DIF: Cognitive Level: Knowledge
REF: p. 627 | Table 26.1
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
1. How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding
techniques to adapt for the child‘s 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: p. 631
OBJ: 5
TOP: Feeding Infant with CHF
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select all
that apply.)
Hypertrophied right ventricle
Patent ductus arteriosus
Ventral septal defect
Narrowing of pulmonary artery
Dextroposition of aorta
a.
b.
c.
d.
e.
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: p. 627
OBJ: 4
TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. 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
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b.
c.
d.
e.
Dyspnea
Weakness
Dry cough
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: p. 630
OBJ: 3
TOP: “Tet” Spells KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4. Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that
apply.)
Atrial septal defects (ASDs)
Tetralogy of Fallot
Dextroposition of aorta
Patent ductus arteriosus
Ventricular septal defects (VSDs)
a.
b.
c.
d.
e.
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: p. 627
OBJ: 3
TOP: Congenital Heart Defects
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. 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: p. 636
OBJ: 9 | 10
TOP: Primary Hypertension
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 27: The Child with a Condition of the Blood, Blood-Forming Organs, or
Lymphatic System
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
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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?
An egg white
Cream of Wheat
A banana
A carrot
a.
b.
c.
d.
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: p. 642
OBJ: 6
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-old‘s iron deficiency
anemia?
a. “Formula is so expensive. We switched to regular milk right away.”
b. “She almost never drinks water.”
c. “She doesn‘t 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 cow‘s milk contains very little iron, infants should drink iron-fortified formula for
the first year of life.
DIF: Cognitive Level: Application
REF: p. 642
OBJ: 4
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?
With milk
With orange juice
With water
On a full stomach
a.
b.
c.
d.
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: p. 642
OBJ: 4
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
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ANS: D
Christmas disease, or hemophilia B, is caused by the deficiency of factor IX.
DIF: Cognitive Level: Knowledge
REF: p. 647
OBJ: 11
TOP: Christmas Disease
KEY: Nursing Process Step: Implementation
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?
If bleeding occurs, apply pressure, ice, elevate, and rest the extremity.
Children‘s aspirin in lowered doses may be given for joint discomfort.
A firm, dry toothbrush should be used to clean teeth at least twice a day.
Do not permit interactive play with other children.
a.
b.
c.
d.
ANS: A
When bleeding occurs, the traditional approach is to follow RICE—rest, ice, compression,
and elevation.
DIF: Cognitive Level: Application
REF: p. 648
OBJ: 12
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. Benadryl
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: p. 648
OBJ: 15
TOP: Leukemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. What should the nurse closely assess in a child receiving a transfusion?
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: p. 652
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?
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a.
b.
c.
d.
Assessing neurological status
Inserting an intravenous line
Monitoring vital signs during platelet transfusions
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: p. 649
OBJ: 15
TOP: Leukemia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. An adolescent is diagnosed with Hodgkin‘s 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 Hodgkin‘s disease.
DIF: Cognitive Level: Application
REF: p. 653 | Table 27.2
OBJ: N/A
TOP: Hodgkin‘s 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: p. 645 | Table 27.1
OBJ: 8
TOP: Sickle Cell Disease
KEY: Nursing Process Step: Data Collection
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?
“I should give my child a daily iron supplement.”
“It is important for my child to drink plenty of fluids.”
“He needs to wear protective equipment if he plays contact sports.”
“He shouldn‘t receive any immunizations until he is older.”
a.
b.
c.
d.
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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: p. 645
OBJ: 9
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 children‘s 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: p. 643 | Figure 27.4
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: p. 645
OBJ: 16
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?
Decreased T-cell production
Decreased hemoglobin
Increased blood clotting
Increased susceptibility to infection
a.
b.
c.
d.
ANS: D
An overproduction of immature white blood cells increases the child‘s susceptibility to
infection.
DIF: Cognitive Level: Comprehension
REF: p. 650
OBJ: 14 | 15
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TOP: Leukemia
KEY: Nursing Process Step: Data Collection
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?
Notify the charge nurse.
Disconnect intravenous lines immediately.
Give diphenhydramine (Benadryl).
Clamp off blood and keep line open with normal saline.
a.
b.
c.
d.
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
TOP: Blood Transfusion
MSC: NCLEX: Physiological Integrity
REF: p. 652
OBJ: 16
KEY: Nursing Process Step: Implementation
16. What would the nurse include in a teaching plan about mouth care of a child receiving
chemotherapy?
Use commercial mouthwash.
Clean teeth with a soft toothbrush.
Avoid use of a Water-Pik.
Inspect the mouth weekly for ulcerations.
a.
b.
c.
d.
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: p. 652
OBJ: 15
TOP: Leukemia
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17. A 6-year-old child with leukemia asks, “Who will take care of me in heaven?” What is the
best response by the nurse?
“Who do you think will take care of you?”
“Your grandparents and God will take care of you.”
“Your mom will know more about that than I do.”
“Why are you asking me that?”
a.
b.
c.
d.
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: p. 652
OBJ: 18
TOP: Leukemia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18. The nurse is dealing with a preschool child with a life-threatening illness. What should the
nurse remember the child‘s concept of death is at this age?
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a.
b.
c.
d.
That it is final
Only a fear of separation from her parents
That a person becomes alive again soon after death
An understanding based on simple logic
ANS: C
The preschooler views death as reversible and temporary.
DIF: Cognitive Level: Comprehension
REF: p. 655
OBJ: 19
TOP: Nursing Care of the Dying Child
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
19. The nurse notes that a 4-year-old child‘s gums bleed easily and he has bruising and petechiae
on his extremities. Which lab value is consistent with these symptoms?
Platelet count of 25,000/mm3
Hemoglobin level of 8 g/dL
Hematocrit level of 36%
Leukocyte count of 14,000/mm3
a.
b.
c.
d.
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: p. 649
OBJ: 14
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 child‘s 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 bowel.
DIF: Cognitive Level: Analysis
REF: p. 651
OBJ: 14 | 15
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 Hodgkin‘s disease crying. The adolescent says, “I am so
scared.” What is the most appropriate nursing response to this comment?
“I understand how you must feel.”
“You shouldn‘t feel that way.”
“Is this the strongest feeling you‘ve had today?”
“Tell me what‘s got you scared.”
a.
b.
c.
d.
ANS: D
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The nurse should encourage the adolescent to express her feelings and concerns.
DIF: Cognitive Level: Application
REF: p. 655
TOP: Adolescent with Cancer—Fear of Death
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
OBJ: 18
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?
Risk for infection
Risk for hemorrhage
Altered skin integrity
Disturbance in body image
a.
b.
c.
d.
ANS: A
The child with neutropenia is at risk for infection.
DIF: Cognitive Level: Application
REF: p. 651 |Nursing Tip
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 child‘s care.
ANS: C
Hearing is intact even when there is a loss of consciousness.
DIF: Cognitive Level: Analysis
REF: p. 658
OBJ: 18
TOP: Dying Child KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. The nurse is presenting information on the congenital disorder of hemophilia A. What fact
will the nurse include?
It is seen in males and females equally.
It is transmitted by symptom-free females.
It is a sex-linked dominant trait.
It is a defective gene located on the Y chromosome.
a.
b.
c.
d.
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.
DIF: Cognitive Level: Comprehension
REF: p. 647
OBJ: 11
TOP: Hemophilia A
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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25. A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this
disorder goes untreated?
Hemorrhage
Heart failure
Infection
Pulmonary embolism
a.
b.
c.
d.
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: p. 642
OBJ: 5
TOP: Iron Deficiency Anemia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. 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. Petechiae
b. Purpura
c. Ecchymosis
d. Hematoma
e. Lymphadenopathy
ANS: A, B, C, D
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: pp. 648-649 OBJ: 13
TOP: Manifestations of Bleeding
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. 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.)
She will feel less neglected by the parents.
She can make amends for past hostilities to her brother.
She will feel increased helplessness.
She can express her feelings through care.
She can experience being supportive of her parents and brother.
a.
b.
c.
d.
e.
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: p. 658
OBJ: 20
TOP: Siblings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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3. What should be included in the nursing care of a 12-year-old child receiving radiation therapy
for Hodgkin‘s disease? (Select all that apply.)
Application of sunblock
Appetite stimulation
Conservation of energy
Provision for expressions of anger
Preparation for premature sexual development
a.
b.
c.
d.
e.
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: p. 653
OBJ: N/A
TOP: Effects of Radiation
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. What are the classic symptoms of thalassemia major (Cooley‘s anemia)? (Select all that
apply.)
Hepatomegaly
Jaundice
Protruding teeth
Pathological fractures
Renal failure
a.
b.
c.
d.
e.
ANS: A, B, C, D
All of the options are classic signs of thalassemia major except renal failure.
DIF: Cognitive Level: Comprehension REF: p. 646
OBJ: 10
TOP: Thalassemia Major
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. How has synthetic recombinant antihemophilic factor improved the management of
hemophilia? (Select all that apply.)
Eliminates the need for frequent transfusions.
Can be administered by family at home.
Prevents hemorrhage.
Reduces cost of care of the hemophiliac.
Reduces risk of HIV and hepatitis A and B transmission.
a.
b.
c.
d.
e.
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: p. 648
OBJ: 11
TOP: Hemophilia A
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
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6. The family of a child receiving chemotherapy for leukemia should be taught to focus on
which aspect(s) of the child‘s care? (Select all that apply.)
Using a support group
Stimulating appetite
Maintaining adequate hydration
Continuing with scheduled immunizations
Reporting exposure to infectious diseases
a.
b.
c.
d.
e.
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.
DIF: Cognitive Level: Analysis
REF: p. 651
OBJ: 15
TOP: Chemotherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
7. The nurse explains that the COPP medical regimen for the treatment of Hodgkin‘s disease
uses a combination of which drugs? (Select all that apply.)
Vincristine
Cyclophosphamide
Methotrexate
Prednisone
Procarbazine hydrochloride
a.
b.
c.
d.
e.
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: p. 653
OBJ: N/A
TOP: COPP
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
8. 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.)
Delayed bonding with parents
Delayed toilet training
Impaired sense of belonging
Decreased feelings of independence
Impaired speech development
a.
b.
c.
d.
e.
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 child‘s sense of belonging.
DIF: Cognitive Level: Comprehension
REF: p. 654 |Table 27.3
OBJ: 17
TOP: Chronic Illness/Growth and Development
KEY: Nursing Process Step: Data Collection
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MSC: NCLEX: Psychosocial Integrity: Grief and Loss
Chapter 28: The Child with a Gastrointestinal Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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: p. 663
OBJ: 2
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: p. 670
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 infant‘s weight
comprises 77% water.
DIF: Cognitive Level: Application
REF: p. 674 |Figure 28.10 |Table 28.2
OBJ: 9
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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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: p. 676
OBJ: 9
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal
reflux?
Position the infant in the crib on his or her abdomen, with the head elevated.
Administer medication as ordered to stimulate the pyloric sphincter.
Give thin rice cereal with formula before feeding solid foods.
Place the infant in an infant seat after feedings.
a.
b.
c.
d.
ANS: A
After feedings, the infant is placed in a prone position to avoid increased intraabdominal
pressure.
DIF: Cognitive Level: Application
REF: p. 670
OBJ: 7
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?
Diarrhea
Projectile vomiting
Poor appetite
Constipation
a.
b.
c.
d.
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: p. 664
OBJ: 3
TOP: Pyloric Stenosis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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
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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: pp. 681-682 OBJ: 12
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?
Diarrhea
Skin rash
Red stool
Metallic taste
a.
b.
c.
d.
ANS: C
The nurse should advise parents that pyrvinium stains clothing and turns stools red.
DIF: Cognitive Level: Knowledge
REF: p. 682
OBJ: 12
TOP: Worms
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
9. What instruction will the nurse give to parents about preventing the spread and reinfection of
pinworms?
a. Keep children‘s 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 child‘s fingernails
short. Pinworms are not spread from person to person.
DIF: Cognitive Level: Comprehension
REF: p. 682
OBJ: 12
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 child‘s diet?
Cooked vegetables
Pretzels
Whole-grain cereal
Yogurt
a.
b.
c.
d.
ANS: C
Dietary modifications for constipation include eating more high-roughage foods such as
whole-grain breads and cereals.
DIF: Cognitive Level: Comprehension
REF: p. 674
OBJ: N/A
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. What description of a child‘s stool characteristic leads the nurse to suspect intussusception?
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a.
b.
c.
d.
Currant jelly
Black and tarry
Green liquid
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: p. 668
OBJ: 6
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
TOP: Intussusception
MSC: NCLEX: Physiological Integrity
REF: p. 668
OBJ: 6
KEY: Nursing Process Step: Implementation
13. Parents ask the nurse how their infant developed a Meckel‘s diverticulum. What condition,
will the nurse explain, is present causing this diagnosis?
The yolk sac remains connected to the intestine.
There is inflammation of the ileocecal valve.
A pouch forms when the vitelline duct fails to disappear.
There is a weakness in the abdominal wall.
a.
b.
c.
d.
ANS: C
If the vitelline duct fails to disappear completely after birth, a blind pouch may form.
DIF: Cognitive Level: Knowledge
REF: p. 668
OBJ: 2
TOP: Meckel‘s 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?
Metabolic alkalosis
Hypocalcemia
Sepsis
Shock
a.
b.
c.
d.
ANS: D
Shock is the greatest threat to life in isotonic dehydration.
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DIF: Cognitive Level: Comprehension
REF: p. 677
OBJ: 9
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
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: p. 684 | Table 28.8
OBJ: 14
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?
Increased lead content of air
Use of aluminum cookware
Deteriorating paint in older buildings
Inhaling smog
a.
b.
c.
d.
ANS: C
The primary source of lead is paint from old, deteriorating buildings.
DIF: Cognitive Level: Knowledge
TOP: Lead Poisoning
MSC: NCLEX: Physiological Integrity
REF: p. 685
OBJ: 15
KEY: Nursing Process Step: Planning
17. A frightened mother calls the pediatrician‘s office because her child swallowed dishwashing
detergent. What is the most appropriate action?
Induce vomiting by giving the child syrup of ipecac.
Take the child to the local emergency department.
Give the child activated charcoal mixed with juice.
Give the child milk to soothe affected mucous membranes.
a.
b.
c.
d.
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: p. 682
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?
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a.
b.
c.
d.
“I‘ve been airing out the house on these nice breezy days.”
“My child often goes out to the garden and pulls up a carrot to eat.”
“She runs barefoot so much I have to wash her feet at least twice a day.”
“We just remodeled our bathroom at home.”
ANS: B
The child can ingest roundworm eggs from contaminated soil.
DIF: Cognitive Level: Comprehension
REF: p. 682
OBJ: 12
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
ANS: C
Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate
malabsorption.
DIF: Cognitive Level: Comprehension
REF: p. 667
OBJ: 4
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?
Wheat
Oats
Barley
Rice
a.
b.
c.
d.
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: p. 667
OBJ: 4
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 nurse‘s priority goal of the infant‘s care?
Prevent fluid and electrolyte imbalance.
Prevent nutritional deficiency.
Prevent skin breakdown.
Prevent malabsorption.
a.
b.
c.
d.
ANS: A
The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance.
DIF: Cognitive Level: Application
TOP: Gastroenteritis
REF: p. 670
OBJ: N/A
KEY: Nursing Process Step: Planning
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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?
Soft foods with rice, bananas, toast, and applesauce
Small amounts of clear fluids such as gelatin
An oral rehydrating solution, such as Pedialyte
Chicken soup because it is high in sodium
a.
b.
c.
d.
ANS: C
An oral rehydrating solution is recommended to replace fluids and electrolytes lost from
frequent bowel movements.
DIF: Cognitive Level: Application
REF: pp. 671-672 OBJ: 9
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-doll limpness (hypotonia) and appear wary of
their caregivers.
DIF: Cognitive Level: Comprehension
REF: p. 679
OBJ: 10
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?
Pointing out errors that the nurse observes when the mother is caring for the infant
Discussing negative characteristics of the infant with the mother
Having the nurse provide as much of the infant‘s care as possible
Teaching the mother about the developmental milestones to expect in the next few
months
a.
b.
c.
d.
ANS: D
The nurse can increase parent‘s knowledge of growth and development by providing
anticipatory guidance about normal developmental milestones.
DIF: Cognitive Level: Application
REF: p. 679
OBJ: 10
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 son‘s 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.”
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d. “We‘re not big meat eaters.”
ANS: A
Vitamin C is destroyed by heat.
DIF: Cognitive Level: Comprehension
REF: p. 680
OBJ: 10
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: p. 681
OBJ: 11
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: p. 674
OBJ: 8
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 child‘s pH falls in the same line as the HCO3–,
the problem is metabolic (see Table 27-4).
DIF: Cognitive Level: Analysis
REF: p. 678 | Table 28.5
OBJ: 9
TOP: Fluid and Electrolyte Imbalance
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying.
What is the most appropriate nursing action?
Delay feeding the child for 6 hours.
Offer regular formula thinned with water.
Give small amounts of regular formula thickened with cereal.
Allow 1 ounce of glucose water at frequent intervals.
a.
b.
c.
d.
ANS: D
Small oral feedings of glucose water are given after recovery from anesthesia. Feedings are
gradually increased to larger amounts of regular formula or breastmilk.
DIF: Cognitive Level: Application
REF: p. 665
OBJ: 9
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: p. 675
OBJ: 9
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?
“I keep the poison control center phone number easily accessible.”
“All medication is kept out of reach in a locked cabinet.”
“I keep a bottle of syrup of ipecac handy.”
“Our garden is free from marigolds.”
a.
b.
c.
d.
ANS: C
Traditionally, syrup of ipecac was the treatment of choice to remove some types of poisons
from a child‘s 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
to the hospital emergency 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: p. 682
OBJ: 13
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?
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a.
b.
c.
d.
2-month-old with a urine output of 150 mL in 24 hours
3-year-old with a urine output of 650 mL in 24 hours
8-year-old with a urine output of over 1000 mL in 24 hours
14-year-old with a urine output of 800 mL in 24 hours
ANS: A
The urine output of a 2-month-old infant should be between 400 and 500 mL/24 hours.
DIF: Cognitive Level: Application
REF: p. 677 |Table 28.3
OBJ: 9
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Adaptation: Physiological Integrity
MULTIPLE RESPONSE
1. What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select
all that apply.)
Give a formula thinned with water.
Burp the infant before and during feeding.
Give the feeding slowly.
Refeed if the infant vomits.
Position infant on left side after feeding.
a.
b.
c.
d.
e.
ANS: B, C, D
Children with pyloric stenosis are given formula or breastmilk 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: p. 665
OBJ: 3
TOP: Pyloric Stenosis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. What assessment(s) would lead a nurse to suspect Hirschsprung‘s disease in a 1-month-old
infant? (Select all that apply.)
Ribbon-like stools
Fever
Failure to thrive
Vomiting
Diminished peristalsis
a.
b.
c.
d.
e.
ANS: A, B, C, D, E
All options are significant indicators of Hirschsprung‘s disease.
DIF: Cognitive Level: Comprehension
REF: pp. 667-668 OBJ: 5
TOP: Hirschsprung‘s Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. What sign(s) indicate(s) moderate dehydration? (Select all that apply.)
a. 10% weight loss
b. Dry mucous membranes
c. Normal anterior fontanel
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d. Increased urinary output
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: p. 676 | Table 28.2
OBJ: 9
TOP: Moderate Dehydration
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. A child is brought into the ED with suspected appendicitis. What signs and symptoms does
the nurse expect to assess? (Select all that apply.)
Left lower quadrant pain
Guarding
Rebound tenderness
Decreased C-reactive protein
Pain on lifting thigh when supine
a.
b.
c.
d.
e.
ANS: B, C, E
With appendicitis on examination, characteristic tenderness in the right lower quadrant known
as McBurney‘s 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: pp. 680-681 OBJ: 1
TOP: Appendicitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. 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.)
Hyperactivity
White streak in hair
Edematous abdomen
Slowed growth
Thick, oily hair
a.
b.
c.
d.
e.
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.
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DIF: Cognitive Level: Comprehension
REF: p. 680
OBJ: 10
TOP: Nutritional Deficiencies
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. The nurse explains the medically accepted definition of constipation is fewer than
bowel movements in a 2-week period.
ANS:
seven
The medically accepted definition of constipation is fewer than seven bowel movements in a
2-week period.
DIF: Cognitive Level: Knowledge
REF: p. 674
OBJ: N/A
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 29: The Child with a Genitourinary Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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?
“My daughter should wash and wipe the perineal area from front to back.”
“I am only going to have my daughter wear cotton underwear.”
“It is acceptable to take frequent bubble baths.”
“She needs to drink lots of fluids and void frequently.”
a.
b.
c.
d.
ANS: C
Oils in bubble bath and similar products are known to irritate the urethra.
DIF: Cognitive Level: Comprehension
REF: p. 694 | Nursing Tip
OBJ: 6
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?
No intervention is necessary as the defect will correct itself over time.
Surgical repair of the hypospadias is done before 18 months of age.
Corrective surgery is usually delayed until the preschool age.
Repairing the defect will increase the risk of testicular cancer.
a.
b.
c.
d.
ANS: B
Treatment of hypospadias consists of surgical repair and is usually performed before 18
months of age.
DIF: Cognitive Level: Comprehension
REF: p. 693
OBJ: 5
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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: p. 699 | Table 29.3
OBJ: 9
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
TOP: Nephrotic Syndrome
MSC: NCLEX: Physiological Integrity
REF: p. 697
OBJ: 6
KEY: Nursing Process Step: Data Collection
5. During a physical assessment of a hospitalized 5-year-old child, 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: p. 692
OBJ: 1
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
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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: p. 699
OBJ: 9
TOP: Acute Glomerulonephritis
KEY: Nursing Process Step: Planning
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: p. 694 | Table 29.2
OBJ: 12
TOP: Obstructive Uropathy—Urinary 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.
DIF: Cognitive Level: Comprehension
REF: p. 698
OBJ: 6
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?
Ibuprofen, an anti-inflammatory agent
Furosemide (Lasix), a diuretic
Ciprofloxacin (Cipro), an antibiotic
Cyclophosphamide (Cytoxan), an antisuppressant
a.
b.
c.
d.
ANS: D
A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have
proven ineffective.
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DIF: Cognitive Level: Application
REF: p. 694
OBJ: 9
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: p. 699
OBJ: 9
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 child
diagnosed with Wilms‘ tumor?
Performing range-of-motion exercises on lower extremities
Palpating the abdomen
Assessing for bowel sounds
Percussing ankle and knee reflexes
a.
b.
c.
d.
ANS: B
Palpation of the abdomen could disturb the tumor and cause the malignancy to spread.
DIF: Cognitive Level: Application
REF: p. 699 | Safety Alert
OBJ: 10
TOP: Wilms‘ Tumor
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. Parents are speaking with the urologist about their son‘s undescended testicle. Which
statement by the child‘s 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.
DIF: Cognitive Level: Application
REF: p. 700
OBJ: 1 | 5
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?
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a.
b.
c.
d.
Cystometrogram
Cystoscopy
Voiding cystourethrogram
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
TOP: Diagnostic Procedures
MSC: NCLEX: Physiological Integrity
REF: p. 695
OBJ: 1
KEY: Nursing Process Step: Planning
14. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the
nurse recognize these signs and symptoms indicate?
Urinary tract infection
Nephrotic syndrome
Acute glomerulonephritis
Vesicoureteral reflux
a.
b.
c.
d.
ANS: A
Urinary frequency and pain during micturition are symptoms of acute urinary tract infection.
DIF: Cognitive Level: Comprehension
REF: p. 691
OBJ: 6
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 child‘s position frequently.
c. Keep the head of the child‘s 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: p. 697
OBJ: 9
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?
“I will make sure he gets his measles vaccine as soon as he gets home.”
“He can stop taking his medication next week.”
“I should check his urine for protein when he goes to the bathroom.”
“He should eat a low-protein diet for the next few weeks.”
a.
b.
c.
d.
ANS: C
The parents should be instructed to keep a daily record of the child‘s urinary proteins.
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DIF: Cognitive Level: Application
REF: p. 697
OBJ: 9
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
child‘s history, what does the nurse recognize as the probable cause?
Recovery from German measles 2 months ago
Dysuria since the previous night
A history of allergy
A sore throat 2 weeks ago
a.
b.
c.
d.
ANS: D
Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which
causes an allergic-type response that alters the effectiveness of the glomeruli.
DIF: Cognitive Level: Comprehension
REF: p. 698
OBJ: 9
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?
Milk
Grape juice
Apple juice
Orange juice
a.
b.
c.
d.
ANS: C
Juices such as apple or cranberry help maintain acidity of urine.
DIF: Cognitive Level: Comprehension
REF: p. 696 | NCP 29.1
OBJ: 6
TOP: Acute Urinary Tract Infection
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19. The 6-year-old child scheduled for an orchiopexy shyly asks the nurse, “What are they going
to do to me ‗down there‘?” What is the nurse‘s best response?
“They are going to fix you up ‗down there‘.”
“They will move your testicle from your abdomen to your scrotum.”
“What do you think your doctor is going to do?”
“You shouldn‘t worry. Your doctor knows exactly what to do.”
a.
b.
c.
d.
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: p. 700
OBJ: 11 | 12
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
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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: p. 699
OBJ: 12
TOP: Postnephrectomy Instruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21. The parents of a newborn are concerned that their son‘s scrotum is enlarged and swollen on
one side. What is the nurse‘s best response?
“It is very common in the newborn that one gonad is larger than the other.”
“Birth trauma caused bruising to the scrotum. It will reduce in size in a few days.”
“It is a collection of fluid that will most likely correct itself in a year.”
“The doctor will drain this collection of blood before your baby is discharged.”
a.
b.
c.
d.
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: p. 700
OBJ: 5
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.
DIF: Cognitive Level: Comprehension
REF: p. 700
OBJ: 5
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?
Urinary tract infection
Nephrosis
Torsion
Phimosis
a.
b.
c.
d.
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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: p. 700
OBJ: 1 | 5
TOP: Torsion
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
1. 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.)
Dehydration
Renal disease
Need for steroid therapy
Diabetes
Pituitary malfunction
a.
b.
c.
d.
e.
ANS: A, B, C
Increased BUN can indicate dehydration, renal disease, and/or need for steroid therapy.
DIF: Cognitive Level: Analysis
REF: p. 692 | Table 29.1
OBJ: 4
TOP: Diagnostic Tests
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
2. What will the nurse caring for a newborn with exstrophy of the bladder include in the care?
(Select all that apply.)
Diaper infant tightly.
Protect skin around bladder.
Position infant on back.
Prepare for surgical closure.
Cover exposed bladder with shield.
a.
b.
c.
d.
e.
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: p. 693
OBJ: 5
TOP: Exstrophy of the Bladder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
3. The nurse caring for a child with nephrotic syndrome is alert to which classic symptoms of
this disorder? (Select all that apply.)
Proteinuria
Grossly bloody urine
Hyperalbuminemia
Fatigue
Generalized edema
a.
b.
c.
d.
e.
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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: pp. 695-697 OBJ: 9
TOP: Nephrotic Syndrome
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
4. 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: p. 700
OBJ: 12
TOP: Impact of Surgery on Preschoolers KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. What special considerations are related to long-term prednisone therapy in preschoolers?
(Select all that apply.)
Delayed immunization
Hypertension
Enlargement of the sex organs
Alteration in nutrition
Increased risk for infection
a.
b.
c.
d.
e.
ANS: A, E
Delayed immunization and greater risk for infection are concerns relative to long-term
prednisone therapy.
DIF: Cognitive Level: Comprehension
REF: p. 698
OBJ: 9
TOP: Long-Term Prednisone Therapy
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
1. The nurse is measuring output on an infant on the pediatric unit. When weighing the diaper
and subtracting the weight of the dry diaper, the nurse records 30 g and documents this as
mL.
ANS:
30
Diapers may be weighed on a gram scale before application and after removal (1 g = 1 mL).
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DIF: Cognitive Level: Analysis
REF: p. 698
OBJ: 3
TOP: Urinary Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques
Chapter 30: The Child with a Skin Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a
2-month-old infant. How is infant skin different from adult skin?
Less perfusion
Greater moisture
More perspiration
Greater absorption
a.
b.
c.
d.
ANS: D
The child‘s skin has a dramatically greater ability to absorb than does that of the adult.
DIF: Cognitive Level: Comprehension
REF: p. 703 | Figure 30.1
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 fever–type allergies.
DIF: Cognitive Level: Knowledge
REF: p. 709
OBJ: 6
TOP: Infantile Eczema
KEY: Nursing Process Step: Planning
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?
Apply skin lotions in a circular motion.
Apply prescribed ointments with a gloved hand.
Apply as much and as frequently as relieves the symptoms.
Choose lanolin-based ointments.
a.
b.
c.
d.
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
TOP: Infantile Eczema
REF: p. 709
OBJ: 7 | 8
KEY: Nursing Process Step: Implementation
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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?
Report it immediately because it may be a staphylococcus infection.
Keep the affected area dry and clean.
Teach the parents how to care for seborrheic dermatitis.
Chart the finding because it may be the beginning of a strawberry nevus.
a.
b.
c.
d.
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
TOP: Staphylococcal Infection
MSC: NCLEX: Physiological Integrity
REF: p. 711
OBJ: 3
KEY: Nursing Process Step: Implementation
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–water solution through the hair with a fine-tooth comb and then
shampooing is an initial step toward eradication.
DIF: Cognitive Level: Application
REF: p. 713
OBJ: 9
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?
Citrus fruit and juice
Eating shellfish
Alcohol consumption
Taking corticosteroids
a.
b.
c.
d.
ANS: C
Consumption of alcohol while taking griseofulvin will cause severe tachycardia.
DIF: Cognitive Level: Comprehension
REF: p. 712
OBJ: 9
TOP: Tinea Pedis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7. What should the nurse suggest before a 17-year-old girl starts 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.
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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: p. 709
OBJ: 5
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?
First-degree
Second-degree superficial
Second-degree deep dermal
Third-degree
a.
b.
c.
d.
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: p. 716 | Table 30.2
OBJ: 10
TOP: Burns
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. A child has sustained a second-degree deep thermal burn to the hand. What is the best first
action to take?
Immerse the burned area in cold water.
Apply ice to the burned area.
Break any blisters that are present.
Apply petroleum jelly to the burned skin.
a.
b.
c.
d.
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: p. 716 | Table 30.2
OBJ: 10 | 12
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
OBJ: 10
TOP: Burns
MSC: NCLEX: Physiological Integrity
REF: p. 720 | Box 30.2
KEY: Nursing Process Step: Data Collection
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11. What would help the child with a serious burn meet nutritional needs during the subacute
phase of recovery?
Decrease calories because the child will be on bed rest and will not need as many.
Increase calories and protein to compensate for the healing process.
Increase fat to replace the layer of fat next to the burned skin.
Decrease carbohydrates and starches because the pancreas is strained by the
healing process.
a.
b.
c.
d.
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: p. 721
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?
“I apply the medication after I give my child a bath.”
“I rub the ointment in a circular motion over the rash.”
“I increased the amount of cream because the rash was not improving.”
“I use powder and cornstarch to keep the skin dry.”
a.
b.
c.
d.
ANS: A
Absorption of topical medications is best when preparations are applied after a warm bath.
DIF: Cognitive Level: Comprehension
REF: p. 711
OBJ: 7
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 body‘s 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?
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: p. 718
OBJ: 11
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 infant‘s 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
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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: p. 705 | Figure 30.3
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 have caused a heat rash on her infant. The nurse
observes tiny pinhead-sized reddened papules on the infant‘s 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: p. 706 | Figure 30.5
OBJ: 3
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 baby‘s
cradle cap?”
a. “Rub baby oil on the infant‘s head at night and shampoo the hair the next
morning.”
b. “Use a brush with firm bristles to loosen the scales on the baby‘s head several
times a day.”
c. “Wash the baby‘s head every night with a dandruff-control shampoo.”
d. “Lubricate the baby‘s 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: p. 707 | Figure 30.7
OBJ: 7
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 for the infant with eczema?
a. “Wool is the best fabric for the infant‘s clothing.”
b. “I should avoid laundry detergents with fragrances.”
c. “I put cotton gloves on the infant‘s hands.”
d. “The infant‘s fingernails are kept short.”
ANS: A
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Clothing should be made of cotton. Wool is avoided because of its allergy potential.
DIF: Cognitive Level: Comprehension
REF: p. 711
OBJ: 2
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?
Eliminating chocolate, peanuts, and cola from the diet
Washing the face with a cleansing product frequently
Planning indoor activities to avoid sun exposure
Eating a balanced diet and getting sufficient rest
a.
b.
c.
d.
ANS: D
General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help
prevent exacerbations.
DIF: Cognitive Level: Comprehension
REF: p. 708
OBJ: 4
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.
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: p. 722
OBJ: 14
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
nurse‘s first priority?
Assess respiratory status.
Administer pain medication.
Remove clothing.
Insert a Foley catheter.
a.
b.
c.
d.
ANS: A
Airway assessment and establishing an airway are the initial priorities.
DIF: Cognitive Level: Application
REF: p. 717
OBJ: 10 | 12
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
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b. Urinary burning and frequency
c. Breast engorgement
d. Vaginitis
ANS: D
Antibiotic therapy can cause a monilial vaginitis.
DIF: Cognitive Level: Comprehension
REF: p. 709
OBJ: 5 | 7
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 anticipate?
a. Diverticulitis
b. Stress diarrhea
c. Curling‘s ulcer
d. Perforated bowel
ANS: C
Curling‘s ulcer is a complication of burn victims resulting from the stress of their trauma.
DIF: Cognitive Level: Application
REF: p. 718
OBJ: 13
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?
Hands and arms
Feet and legs
Fingers and toes
Head and torso
a.
b.
c.
d.
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: p. 722
OBJ: 14
TOP: Frostbite
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24. An adolescent is at the pediatrician‘s 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: p. 714
OBJ: 9
TOP: Scabies
KEY: Nursing Process Step: Data Collection
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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.
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: pp. 711-712 OBJ: 3 | 4
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 child 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: p. 718
OBJ: 13
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?
Tuberous sclerosis
Eczema
Psoriasis
Systemic lupus erythematosus
a.
b.
c.
d.
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: p. 706
OBJ: N/A
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, fluid-filled blister?
a. Pustule
b. Papule
c. Wheal
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d. Vesicle
ANS: D
A vesicle is an elevated, fluid-filled blister (cold sore, chicken pox).
DIF: Cognitive Level: Comprehension
REF: p. 705| Box 30.1
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?
Hospitalization will be brief.
Analgesics should be given immediately after dressing changes.
Contact with peers should be maintained.
Parents usually handle injury worse than the child.
a.
b.
c.
d.
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: p. 721
OBJ: 11 | 13
TOP: Burns
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. 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.
DIF: Cognitive Level: Knowledge
REF: pp. 705-706 OBJ: 3
TOP: Strawberry Nevus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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2. 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: pp. 707-708 OBJ: N/A
TOP: Avoiding Diaper Rash
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. 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.)
Steroids
Phenytoin
Phenobarbital
Aspirin
Oral contraceptives
a.
b.
c.
d.
e.
ANS: A, B, C
Long-term use of steroids, phenytoin, phenobarbital, lithium, and vitamin B12 can cause acne.
DIF: Cognitive Level: Knowledge
REF: p. 709
OBJ: 5
TOP: Acne
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
4. 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: p. 710
OBJ: 6
TOP: Infantile Eczema
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. Which factor(s) activate the herpes simplex virus type I? (Select all that apply.)
a. Stress
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b.
c.
d.
e.
Sun
Menses
Fever
Food allergies
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: p. 709
OBJ: 4
TOP: Herpes Simplex Type I
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
1. 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 total body surface area (TBSA) 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: p. 714 | Figure 30.15
OBJ: 10 | 11 | 13
TOP: BSA Burn Estimation
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. The nurse assesses a major burn as a full-thickness burn involving
% or more of the
body surface.
ANS:
10
A full-thickness burn involving 10% or more of the body surface is considered a major burn.
DIF: Cognitive Level: Knowledge
REF: p. 711
OBJ: 10
TOP: Burns
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
Chapter 31: The Child with a Metabolic Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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.
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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: p. 725
OBJ: 2
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: p. 727
OBJ: 7
TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
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?
There is an absolute deficiency of insulin.
Insufficient quantities of insulin are produced by the pancreas.
Oral hypoglycemic agents can control it.
Insulin deficiency is caused by another disease affecting the pancreas.
a.
b.
c.
d.
ANS: A
Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete
deficiency of insulin.
DIF: Cognitive Level: Comprehension
REF: p. 728 | Table 31.2
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?
Notify the charge nurse.
Give the patient a snack of graham crackers and milk.
Ambulate the patient in the hall for a short time.
Give the patient more insulin according to the sliding scale.
a.
b.
c.
d.
ANS: B
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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: p. 737 | Table 31.6
OBJ: 8 | 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?
Walk the patient in the hall for 10 minutes.
Allow the patient a short nap.
Give her a cup of orange juice.
Test her blood with a glucometer and give insulin according to the sliding scale.
a.
b.
c.
d.
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: p. 736
OBJ: 7 | 8
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?
“I carry a piece of hard candy with me in case I start to feel shaky.”
“I make sure I have emergency money when I have soccer practice or a game.”
“Sometimes I skip my breakfast when I have a game in the morning.”
“I play in soccer games that are scheduled after dinner.”
a.
b.
c.
d.
ANS: C
Blood glucose is high after meals. The child with type 1 diabetes mellitus who skips a meal
before exercise is at risk for hypoglycemia.
DIF: Cognitive Level: Comprehension
REF: p. 738
OBJ: 8
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?
“My pancreas is sick and needs insulin until it is well.”
“I will need to take my insulin every day.”
“I need to keep a piece of candy in my pocket in case I start to feel shaky.”
“My mom has to give me insulin shots twice a day.”
a.
b.
c.
d.
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: p. 728 | Table 31.2
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OBJ: 5
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?
Control intake of carbohydrates and consume fewer calories.
Focus on complex carbohydrates and eat foods high in fiber.
Obtain most calories from proteins and fats.
Eat a diet low in fat and low in complex carbohydrates.
a.
b.
c.
d.
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: p. 737
OBJ: 8
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 child‘s 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: p. 730 | Table 31.4
OBJ: 6
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?
Hypothyroidism
Hyperthyroidism
Type 1 diabetes mellitus
Tay-Sachs disease
a.
b.
c.
d.
ANS: A
The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing
noisy respiration.
DIF: Cognitive Level: Analysis
REF: p. 726
OBJ: 3
TOP: Hypothyroidism
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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11. What is an important consideration for the school-age child taking DDAVP for diabetes
insipidus?
Observe for signs of water deprivation.
Restrict his physical education program.
Arrange for the child to use the bathroom when needed.
Limit fluid intake other than during the lunch period.
a.
b.
c.
d.
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: pp. 726-727 OBJ: 4
TOP: Diabetes Insipidus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12. 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 body‘s counter-regulatory hormones are released, producing
the symptoms described.
DIF: Cognitive Level: Analysis
TOP: Somogyi Phenomenon
MSC: NCLEX: Physiological Integrity
REF: p. 736
OBJ: 11
KEY: Nursing Process Step: Data Collection
13. 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 if you are a carrier of 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: p. 725
OBJ: 2
TOP: Tay-Sachs Disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. 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.”
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b. “I am using a different brand now because it costs less money.”
c. “I don‘t 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: p. 726
OBJ: 3
TOP: Levothyroxine (Synthroid)
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
15. 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?
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: p. 726
OBJ: 4
TOP: Diabetes Insipidus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16. 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?
Polyuria
Cough
Weight loss
Lethargy
a.
b.
c.
d.
ANS: D
Signs of water intoxication include edema, lethargy, nausea, and central nervous system signs.
DIF: Cognitive Level: Comprehension
REF: p. 726
OBJ: 4
TOP: Diabetes Insipidus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. The parents of a child newly diagnosed with diabetes mellitus tell the nurse, “Our son‘s body
is resistant to insulin.” With what does the nurse recognize this description is consistent?
Type 1, insulin-dependent diabetes mellitus
Type 2, non–insulin-dependent diabetes mellitus
Maturity-onset diabetes of youth
Drug-induced diabetes
a.
b.
c.
d.
ANS: B
Type 2, non–insulin-dependent diabetes mellitus is caused by insulin resistance or failure of
the body to use the insulin.
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DIF: Cognitive Level: Comprehension
REF: p. 728
OBJ: 5
TOP: Insulin Resistance
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18. 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: p. 733
OBJ: 9
TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
19. The nurse discussed treatment of hypoglycemia with an adolescent. Which statement by the
adolescent 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: p. 736
OBJ: 7
TOP: Diabetes Mellitus
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20. Why does the nurse instruct an 11-year-old diabetic child to use the side of the finger for
blood testing?
It has fewer capillaries.
It is easier to puncture.
It is less likely to become infected.
It has fewer nerve endings.
a.
b.
c.
d.
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: p. 732
OBJ: 8
TOP: Finger Stick KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
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21. What is the function of an insulin pump?
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: p. 732
OBJ: 8
TOP: Insulin Pump
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22. The nurse is preparing to administer a long-acting insulin. Which insulin is considered long
acting?
Lispro
Aspart
Glargine
Regular
a.
b.
c.
d.
ANS: C
Insulin glargine is a long-acting insulin. Regular is short acting. Lispro and Aspart are rapid
acting.
DIF: Cognitive Level: Knowledge
REF: p. 734
OBJ: 9
TOP: Insulin
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
MULTIPLE RESPONSE
1. When discussing possible causes of diabetes in children, the nurse mentions chromosomal
defects. Which chromosomes are associated with diabetes? (Select all that apply.)
6
7
12
20
21
a.
b.
c.
d.
e.
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: p. 725
OBJ: 5
TOP: Diabetes Mellitus
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. Which food sources are high in soluble fiber? (Select all that apply.)
a. Raw fruits
b. Cooked vegetables
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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: p. 737
OBJ: 8
TOP: Dietary Fiber Sources
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What does the nurse remind the adolescent with diabetes that soluble fiber in the diet can
reduce? (Select all that apply.)
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: p. 737
OBJ: 8
TOP: Fiber in Diet KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. 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: p. 724
OBJ: 3
TOP: Endocrine System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5. 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
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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: p. 726
OBJ: 3
TOP: Levothyroxine (Synthroid) Overdose
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
6. 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 adolescent‘s lifestyle of eating fast foods. Denial of disease is prevalent
in the adolescent.
DIF: Cognitive Level: Comprehension
REF: p. 730 | Table 31.7
OBJ: 8
TOP: Diabetic Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. 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.)
Chest congestion
Ear pain
Fruity breath
Hyperactivity
Nausea
a.
b.
c.
d.
e.
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: p. 730
OBJ: 6
TOP: Ketoacidosis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. 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.”
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e. “Sleep patterns are not established.”
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: p. 736
OBJ: 10
TOP: Insulin Shock
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
COMPLETION
1. 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: p. 733
OBJ: 8
TOP: Insulin Pump
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. The nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level
is
disease.
mg/dL on two separate occasions, and the history is positive for indication of the
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 for the disease.
DIF: Cognitive Level: Comprehension
REF: p. 728
OBJ: 8
TOP: Diagnosis of DM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
3. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can
evaluate average glucose levels over a period of _
ANS:
3; 4
3, 4
3 to 4
three, four
three; four
three to four
to
months.
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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: pp. 729-730 OBJ: 8
TOP: Glycosylated Hemoglobin
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural Disasters, and
the Maternal–Child Patient
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. Which classification of medication would make a child most susceptible to an opportunistic
infection?
Anticonvulsant
Beta-adrenergic agent
Antibiotic
Corticosteroid
a.
b.
c.
d.
ANS: D
Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic
infections.
DIF: Cognitive Level: Knowledge
REF: p. 749
OBJ: 3
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 child asks the nurse how she got the antibodies that kept her from getting
whooping cough. What is the nurse‘s 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.
DIF: Cognitive Level: Comprehension
REF: p. 749
OBJ: 7
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
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d. Pustular
ANS: B
A papule is a circular, reddened elevated area on the skin.
DIF: Cognitive Level: Knowledge
REF: p. 754
OBJ: 2
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: p. 757
OBJ: 5
TOP: Immunizations
KEY: Nursing Process Step: Implementation
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
d. Droplet
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: p. 750
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?
“My child should stay home from school for 6 days after the pox appear.”
“My child can return to school when the rash fades.”
“My child must stay away from other children until all of the lesions have healed.”
“My child is contagious as long as he has a fever.”
a.
b.
c.
d.
ANS: A
The child with varicella is contagious for 6 days after the appearance of the rash.
DIF: Cognitive Level: Comprehension
REF: p. 744| Health Promotion Box
OBJ: 2
TOP: Common Varicella
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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7. Which statement made by a sexually active adolescent girl indicates an understanding of the
prevention of sexually transmitted diseases?
“I always douche after intercourse.”
“I think you can get a vaccination for STDs now.”
“I insist that my partner wear a condom.”
“I am protected because I take the pill.”
a.
b.
c.
d.
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: p. 761 | Nursing Tip
OBJ: 10
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: p. 749
OBJ: 10
TOP: Human Immunodeficiency Virus
KEY: Nursing Process Step: Nursing Diagnosis
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: p. 751 | Figure 32.6
OBJ: 5
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.
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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: p. 746 | Health Promotion Box
OBJ: 3
TOP: Hepatitis A KEY: Nursing Process Step: Implementation
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: p. 743
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. “I‘m wearing this because there are a lot of bacteria in the hospital.”
d. “I might look scary but you won‘t 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.
DIF: Cognitive Level: Application
REF: p. 753
OBJ: 3 | 4
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?
Influenza
Inactivated polio vaccine
Diphtheria, tetanus, acellular pertussis
Hepatitis B
a.
b.
c.
d.
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ANS: A
The influenza vaccine should not be given to children who are allergic to eggs.
DIF: Cognitive Level: Knowledge
REF: p. 756
OBJ: 7
TOP: Nurse‘s Role in Immunizations—Allergy
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?
DTaP subcutaneously
Hib vaccine prepared in a separate syringe
Varicella intramuscularly
Varicella 1 week after the MMR vaccine
a.
b.
c.
d.
ANS: B
Hib vaccine must be given in a separate syringe from other vaccines administered at the same
time.
DIF: Cognitive Level: Knowledge
REF: p. 757
OBJ: 7
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 child‘s 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: p. 745 | Health Promotion Box
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 child‘s parent understands information
related to tick bites?
“I‘ll have my son wear dark clothing on his hike.”
“We should all get the Lyme disease vaccine before our trip.”
“I‘ll get a prescription for amoxicillin to take with us.”
“We will wear long pants and long-sleeved shirts in the woods.”
a.
b.
c.
d.
ANS: D
People should keep skin covered by wearing protective clothing in wooded areas to prevent
tick bites.
DIF: Cognitive Level: Application
REF: p. 747 | Health Promotion
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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?
Finish all of the medication.
Get plenty of fresh air and sunlight.
Take the medication with food.
Take an antacid if the medication causes an upset stomach.
a.
b.
c.
d.
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: p. 761 | Table 32.4
OBJ: 10
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?
The child is now immune to varicella.
The child has varicella but has not yet broken out.
The child is infected with varicella but is not contagious.
The child does not have varicella but has been exposed to it.
a.
b.
c.
d.
ANS: B
The prodromal stage is the initial stage of the communicable disease in which the child is
infected and contagious but does not yet have outward signs of the disease.
DIF: Cognitive Level: Comprehension
REF: p. 748
OBJ: 1 | 2
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: p. 749
OBJ: 1
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
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b. Portal of entry
c. Portal of exit
d. Vector
ANS: B
The chain of infection refers to the way in which organisms spread and infect the individual.
A portal of entry 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 of organisms (e.g., standing,
stagnant water). A vector is an insect or animal that carries and spreads a disease.
DIF: Cognitive Level: Comprehension
REF: p. 749
OBJ: 1
TOP: Chain of Infection
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
MULTIPLE RESPONSE
1. What are the most likely reasons 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 doesn‘t 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: pp. 761-762 | Table 32.4
OBJ: 10
TOP: Reporting STDs
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. What sources are examples of acquired immunity? (Select all that apply.)
a. Gamma globulin
b. The disease
c. Maternal antibodies
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: p. 749
OBJ: 1
TOP: Acquired Immunity
KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
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3. The well-child clinic nurse is preparing to give which immunizations to a healthy 2-month-old
infant? (Select all that apply.)
DTaP
Hib
IPV
MMR
PCV
a.
b.
c.
d.
e.
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, and rubella are not expected until the child is 1-year old.
DIF: Cognitive Level: Knowledge
REF: p. 757
OBJ: 5
TOP: Inoculations for a 2-Month-Old
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4. 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.)
Small television
Vital documents
Nonperishable food
Pet food
Blankets
a.
b.
c.
d.
e.
ANS: B, C, D, E
The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or
man-made 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: p. 760
OBJ: 9
TOP: Disaster Preparedness
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5. 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 throat culture and assessment 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: p. 748 | Health Promotion
OBJ: 2
TOP: Scarlet Fever
KEY: Nursing Process Step: Implementation
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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
1. 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 14 to
days.
ANS:
21
The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days.
DIF: Cognitive Level: Knowledge
REF: p. 744 | Health Promotion Box
OBJ: 2
TOP: Varicella
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2. The nurse demonstrates proper hand hygiene pointing out that the process should take a
minimum of
seconds.
ANS:
15
Hand hygiene should take a minimum of 15 seconds to complete.
DIF: Cognitive Level: Knowledge
REF: p. 753 | Nursing Tip
OBJ: 4
TOP: Hand Hygiene
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
Chapter 33: The Child with an Emotional or Behavioral Condition
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
MULTIPLE CHOICE
1. A parent asks the nurse to describe what is meant by a “learning disability.” Which is the
nurse‘s 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 child‘s 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 above-average intelligence, but they may experience difficulties in perception,
language, comprehension, and conceptualization.
DIF: Cognitive Level: Comprehension
REF: p. 767
OBJ: N/A
TOP: Learning Disability
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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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. “You‘re 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.
DIF: Cognitive Level: Application
REF: p. 775 | Nursing Tip
OBJ: 10
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, “I‘m not
going to talk about that! It‘s none of your business, anyway! Leave me alone!” How does the
nurse interpret the adolescent‘s 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 child‘s security and creates anxiety.
DIF: Cognitive Level: Analysis
REF: pp. 776-777 OBJ: 13
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 aren‘t home and won‘t be back for 4 hours. That should be enough
time for the pills to work. I‘ve got a hundred of them.”
c. “My dad will be home first, so he‘ll find me. So I think I‘ll use his gun. I hope he
didn‘t lock the cabinet.”
d. “My girlfriend is here with me. She told me to call because I was talking crazy
about killing myself.”
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: p. 772 | NCP 33.1
OBJ: 9 | 10
TOP: Suicide
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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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?
He gives up the band to spend time with his girlfriend.
He spends all of his time at the library studying to qualify for the honor society.
He gives his guitar away and spends his time listening to music in his room.
He withdraws all of his money out of the bank to buy an expensive leather jacket.
a.
b.
c.
d.
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: p. 768
OBJ: 5 | 9 | 10
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 nurse‘s 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 with her husband‘s drinking, 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: pp. 776-777 OBJ: 13
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?
Seat the child in the back of the room to prevent distractions for other children.
Pair the child with a student buddy to offer reminders to pay attention.
Divide work assignments into shorter periods with breaks in between.
Separate the child from others to increase his focus on schoolwork.
a.
b.
c.
d.
ANS: C
The child with ADHD needs breaks between periods of work and study.
DIF: Cognitive Level: Application
REF: p. 770 | Health Promotion Box
OBJ: 7
TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
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8. How does the nurse describe a person who is bulimic?
a. Severely underweight
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: p. 771
OBJ: 8
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: p. 768
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?
a. “There really isn‘t anything to worry about. Don‘t they say you can never be too
thin?”
b. “My daughter just doesn‘t 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: p. 770 | Figure 33.3
OBJ: 8
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 child‘s chronological age as a guide for communication.
c. Keep the child‘s 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.
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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: p. 768
OBJ: 4
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?
Significant signs of the disorder manifest by 1 year of age.
The earliest signs of autism are impulsivity and overactivity.
Autism is usually diagnosed when the child goes to elementary school.
Medications can cure childhood autism.
a.
b.
c.
d.
ANS: A
Failure to use eye contact and look at others, poor attention span, and poor orienting to one‘s
name are significant signs of dysfunction by 1 year of age.
DIF: Cognitive Level: Comprehension
REF: p. 768
OBJ: 4
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: pp. 775-776 OBJ: 11
TOP: Substance Abuse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
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?
Barbiturates
Cocaine
Methamphetamine
Marijuana
a.
b.
c.
d.
ANS: C
“Speed” is the street name for methamphetamine.
DIF: Cognitive Level: Knowledge
REF: p. 775 | Table 33.2
OBJ: 11
TOP: Substance Abuse
KEY: Nursing Process Step: Data Collection
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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?
Psychiatrist
Psychoanalyst
Psychologist
Counselor
a.
b.
c.
d.
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: p. 767
OBJ: 2
TOP: Psychoanalytic Professional
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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: p. 767
OBJ: 2
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?
Sedating the child
Impairing cognition
Causing hypotension
Creating fluid retention
a.
b.
c.
d.
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: p. 768
OBJ: 4
TOP: Autism
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18. A 9-year-old child 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
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d. Elevation of temperature
ANS: A
Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and
general sensorium.
DIF: Cognitive Level: Application
REF: p. 775
OBJ: 11
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?
Becomes hyperactive and ceases to read.
Reads the word dog as God.
Makes up a story rather than reading the text.
Stutters as he reads.
a.
b.
c.
d.
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: pp. 767-768 OBJ: N/A
TOP: Dyslexia
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
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: p. 776
OBJ: 11
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: p. 776
OBJ: 11
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
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b. Super coper
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: pp. 776-777 OBJ: 3
TOP: Child of an Alcoholic
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
MULTIPLE RESPONSE
1. The nurse working with children from dysfunctional families must be prepared to address
what associated problem(s)? (Select all that apply.)
Lack of trust
Acting out
Exaggerated self-confidence
Blaming others for problems
Depression
a.
b.
c.
d.
e.
ANS: A, B, E
Children from dysfunctional families exhibit lack of trust, act out, and show signs of
depression.
DIF: Cognitive Level: Comprehension
REF: p. 767
OBJ: 3
TOP: Dysfunctional Families
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
2. 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.)
Masturbation
Food fads
Stuttering
Aggressive behavior
Nonnutritive sucking
a.
b.
c.
d.
e.
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: p. 767
OBJ: 3
TOP: Nervous Tension
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
3. The nurse states that the members of a mental health team for child guidance include which
member(s)? (Select all that apply.)
a. Psychiatrist
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b.
c.
d.
e.
Pediatrician
Psychologist
Dietitian
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: p. 767
OBJ: 2
TOP: Members of the Child Guidance Team
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
4. 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: p. 776
OBJ: 11
TOP: Inhaling Hydrocarbons
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5. The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s)
cause this disorder? (Select all that apply.)
Discomfort relative to emerging sexuality
Fear of intimacy
Pervasive high self-esteem
Egocentricity
Inability to meet developmental needs
a.
b.
c.
d.
e.
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: p. 770
OBJ: 8
TOP: Anorexia Nervosa
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
6. 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
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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: p. 770 | Figure 33.1
OBJ: 8
TOP: Anorexia Nervosa
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. 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
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: pp. 768-769 OBJ: 5
TOP: Obsessive Compulsive Disorder
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8. A child is diagnosed with attention-deficit hyperactivity disorder (ADHD). Which
characteristics would the nurse assess in this child? (Select all that apply.)
Social anxiety
Impulsivity
Hyperactivity
Distractibility
Inattention
a.
b.
c.
d.
e.
ANS: B, C, D, E
ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.
DIF: Cognitive Level: Knowledge
REF: p. 769
OBJ: 6 | 7
TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Chapter 34: Complementary and Alternative Therapies in Maternity and Pediatric
Nursing
Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition
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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?
Acupuncture
Acupressure
Aromatherapy
Ayurveda
a.
b.
c.
d.
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: p. 784
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.
DIF: Cognitive Level: Comprehension
REF: p. 783
OBJ: 3
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?
Lavender
Ephedra
Ginseng
Kava-kava
a.
b.
c.
d.
ANS: A
Lavender, chamomile, and sandalwood essential oils are useful in aromatherapy for children
with chronic pain.
DIF: Cognitive Level: Knowledge
REF: p. 785 | Nursing Tip
OBJ: 2
TOP: Alternative Health Practices—Aromatherapy
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
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b. Wintergreen
c. Thyme
d. Citrus
ANS: D
Citrus is one essential oil that has been shown to be useful during labor and delivery.
DIF: Cognitive Level: Comprehension
REF: p. 785
OBJ: 10
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: pp. 785-786 OBJ: 9
TOP: Guided Imagery
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. A woman taking St. John‘s 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. John‘s 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. John‘s wort and ginseng can cause problems during surgery, and their use should be
discontinued 2 weeks before surgery.
DIF: Cognitive Level: Application
REF: p. 782 | Table 34.1
OBJ: 6
TOP: Herbal Remedies
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?
Evening primrose oil
Echinacea
Milk thistle
Black cohosh
a.
b.
c.
d.
ANS: D
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Black cohosh diminishes hot flashes by reducing luteinizing hormone. It also reduces joint
pain and other menopausal discomforts.
DIF: Cognitive Level: Knowledge
REF: p. 790 | Table 34.4
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.
DIF: Cognitive Level: Comprehension
REF: pp. 780-781 OBJ: 3 | 9
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: p. 780
OBJ: 2
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?
They are lymph nodes.
They are invisible pathways for energy.
They are lines that divide the body into 10 zones.
They are areas of skin that are specifically innervated.
a.
b.
c.
d.
ANS: B
Meridians are invisible pathways through which energy travels to effect acupuncture
treatment.
DIF: Cognitive Level: Knowledge
REF: p. 784 | Figure 34.4
OBJ: 8
TOP: Herbal Remedies: CAM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
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11. Which herbal remedy used by a patient taking warfarin should the nurse report to the
physician?
Angelica (dong quai)
Chamomile
Ginseng
Kava-kava
a.
b.
c.
d.
ANS: A
Angelica prolongs prothrombin time and will synergize the effect of the warfarin.
DIF: Cognitive Level: Application
REF: p. 787 | Table 34.2
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 child‘s asthma?
Should be drunk with large amounts of fluid.
Can be taken with traditional Western medications.
Can be enhanced by drinking hot tea.
May contain mercury, alcohol, or arsenic.
a.
b.
c.
d.
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.
DIF: Cognitive Level: Application
REF: p. 786
OBJ: 9
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: p. 784
OBJ: 9
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?
Diarrhea
Jaundice
Colic
Retinal damage
a.
b.
c.
d.
ANS: C
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Vitamin C can be passed on to a breastfeeding child through breast milk and can cause colic.
DIF: Cognitive Level: Comprehension
REF: p. 788
OBJ: 5
TOP: Vitamin C
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
15. The pregnant patient with a stasis ulcer asks if she might be a candidate for hyperbaric oxygen
therapy (HBOT). What is the nurse‘s 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 baby‘s
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 mother‘s blood can cause closure of the ductus
arteriosus and cause fetal death.
DIF: Cognitive Level: Application
REF: p. 790
OBJ: 2
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.
DIF: Cognitive Level: Comprehension
REF: p. 786
OBJ: 9
TOP: CAM Therapies
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
1. What conditions would a nurse expect to see treated with hyperbaric oxygen therapy
(HBOT)? (Select all that apply.)
Wounds
Carbon monoxide poisoning
Hyperemesis gravidarum
Decompression illness
a.
b.
c.
d.
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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: p. 790
OBJ: 13
TOP: HBOT
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. 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
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: p. 786
OBJ: 11
TOP: Herbal Therapies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3. The nurse points out that light therapy is used in the treatment of patients with which
disorder(s)? (Select all that apply.)
Digestive disorders
Seasonal affective disorder
Inflammatory diseases
Stress disorders
Jaundice
a.
b.
c.
d.
e.
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: p. 784
OBJ: 9
TOP: Light Therapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. What advantage(s) of alternative health care should the nurse outline when providing
information to patients? (Select all that apply.)
Offering more patient control of health care
Offering a variety of health care advisors
Keeping patients from having to make decisions
Using natural products rather than chemical ones
a.
b.
c.
d.
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e. Incorporating cultural beliefs and practices
ANS: A, B, D, E
Alternative health care actually promotes the patient‘s decision making in care.
DIF: Cognitive Level: Comprehension
REF: p. 780
OBJ: 5
TOP: CAM
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
5. 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
Osteopaths combine manipulative therapy including pressure point therapy with traditional
(allopathic) medicine.
DIF: Cognitive Level: Knowledge
REF: p. 783
OBJ: 9
TOP: Osteopathy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort