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Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

1

Table of Contents
Table of Contents
1
Chapter 01: The Past, Present, and Future
2
Chapter 02: Human Reproductive Anatomy and Physiology
12
Chapter 03: Fetal Development
22
Chapter 04: Prenatal Care and Adaptations to Pregnancy
31
Chapter 05: Nursing Care of Women with Complications During Pregnancy
40
Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
50
Chapter 07: Nursing Management of Pain During Labor and Birth
60
Chapter 08: Nursing Care of Women with Complications During Labor and Birth
70
Chapter 09: The Family After Birth
79
Chapter 10: Nursing Care of Women with Complications After Birth
88
Chapter 11: The Nurses Role in Womens Health Care
97
Chapter 12: The Term Newborn
106
Chapter 13: Preterm and Postterm Newborns
116
Chapter 14: The Newborn with a Perinatal Injury or Congenital Malformation
125
Chapter 15: An Overview of Growth, Development, and Nutrition
135
Chapter 16: The Infant
145
Chapter 17: The Toddler
155
Chapter 18: The Preschool Child
164
Chapter 19: The School-Age Child
173
Chapter 20: The Adolescent
182
Chapter 21: The Childs Experience of Hospitalization
191
Chapter 22: Health Care Adaptations for the Child and Family
200
Chapter 23: The Child with a Sensory or Neurological Condition
209
Chapter 24: The Child with a Musculoskeletal Condition
219
Chapter 25: The Child with a Respiratory Disorder
229
Chapter 26: The Child with a Cardiovascular Disorder
238
Chapter 27: The Child with a Condition of the Blood, Blood-Forming Organs, or Lymphatic
System
246
Chapter 28: The Child with a Gastrointestinal Condition
256
Chapter 29: The Child with a Genitourinary Condition
267
Chapter 30: The Child with a Skin Condition
276
Chapter 31: The Child with a Metabolic Condition
286
Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural Disasters and the
Maternal-Child Patient
296
Chapter 33: The Child with an Emotional or Behavioral Condition
305
Chapter 34: Complementary and Alternative Therapies in Maternity and Pediatric Nursing
315

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

2

Chapter 01: The Past, Present, and Future
MULTIPLE CHOICE
1
...
What does
the CNMs scope of practice include?
a
...
Comprehensive prenatal care
c
...
Cesarean sections
ANS: B
The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures
that a backup physician is available in case of unforeseen problems
...
Which medical pioneer discovered the relationship between the incidence of puerperal fever and unwashed
hands?
a
...
Ignaz Semmelweis
c
...
Joseph Lister
ANS: B
Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed
hands of physicians and medical students
...
A pregnant woman who has recently immigrated to the United States comments to the nurse, I am afraid of
childbirth
...
I am afraid I will die
...
Maternal mortality in the United States is extremely low
...
Anesthesia is available to relieve pain during labor and childbirth
...
Tell me why you are afraid of childbirth
...
Your condition will be monitored during labor and delivery
...

DIF: Cognitive Level: Application REF: Page 7-8 OBJ: 8
TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation
4
...
What information does this provide?
a
...
Deaths of fetuses weighing more than 500 g per 10,000 births per year
c
...
Fetal and neonatal deaths per 1000 live births per year
ANS: D
The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year
...
What is the focus of current maternity practice?
a
...
The traditional family unit
c
...
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
...
Who advocated the establishment of the Childrens Bureau?
a
...
Florence Nightingale
c
...
Clara Barton
ANS: A
Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau
...
What was the result of research done in the 1930s by the Childrens Bureau?
a
...

b
...

c
...

d
...

ANS: C
School hot lunch programs were developed as a result of research by the Childrens Bureau on the effects of
economic depression on children
...
What government program was implemented to increase the educational exposure of preschool children?
a
...
Title XIX of Medicaid
c
...
Head Start
ANS: D
Head Start programs were established to increase educational exposure of preschool children
...
What guidelines define multidisciplinary patient care in terms of expected outcome and timeframe from
different areas of care provision?

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

4

a
...
Nursing outcome criteria
c
...
Nursing care plan
ANS: A
Clinical pathways, also known as critical pathways or care maps, are collaborative guidelines that define
patient care across disciplines
...

DIF: Cognitive Level: Knowledge REF: Page 12 OBJ: 14
TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
10
...
What is the next step the student will take to develop a nursing care plan for this child?
a
...

b
...

c
...

d
...

ANS: C
The nurse uses assessment data to select appropriate nursing diagnoses from the NANDA-I list
...

DIF: Cognitive Level: Application REF: Page 11 OBJ: 13
TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
11
...
What resource can the nurse suggest to the student?
a
...
States board of nursing
c
...
Association of Womens Health, Obstetric and Neonatal Nurses
ANS: B
The scope of practice of the LVN/LPN is published by the states board of nursing
...
What was recommended by Karl Cred in 1884?
a
...

b
...

c
...

d
...

ANS: D
In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newborns to reduce the incidence of
blindness
...
What is the purpose of the White House Conference on Children and Youth?
a
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

5

b
...

c
...

d
...

ANS: D
White House Conferences on Children and Youth are held every 10 years to promote comprehensive child
welfare
...
How many hours of hospital stay does legislation currently allow for a postpartum patient who has
delivered vaginally without complications?
a
...
48
c
...
72
ANS: B
Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have
had a cesarean delivery usually stay 4 days
...
How does the clinical pathway or critical pathway improve quality of care?
a
...
Outlines expected progress with stated timelines
c
...
Describes common complications
ANS: B
Critical pathways outline expected progress with stated timelines
...

DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14
TOP: Critical Pathway KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
16
...
What is the nurses best response?
a
...

b
...

c
...

d
...

ANS: A
Gene therapy can replace missing or defective genes
...
The nurse is clarifying information to a patient regarding diagnosis-related groups (DRGs)
...
By determining payment based on diagnosis
b
...
By organizing HMOs
d
...

DIF: Cognitive Level: Comprehension REF: Page 8 OBJ: 11
TOP: DRGs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
18
...
Patient will ambulate in the hall independently for 10 minutes three times a day
...
Nurse will report temperature elevations to the charge nurse
...
Nurse will offer extra liquids at all meals
...
Patient will express pain relief after massage
...

DIF: Cognitive Level: Comprehension REF: Page 12 | Page 14
OBJ: 15 TOP: NICs KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19
...
Provides a uniform style of chart
b
...
All documentation is reflective of the nursing care plan
d
...

DIF: Cognitive Level: Comprehension REF: Page 15-16 OBJ: 22
TOP: Computer Charting KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
20
...
What is the appropriate term for this type of control?
a
...
Insight
c
...
Organization
ANS: A
The term empowerment refers to the control a family has over its own health care decisions
...
A patient in the prenatal clinic is concerned about losing her job because of her pregnancy
...
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
...
6
c
...
12

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

7

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
...
What term appropriately describes the nurse who is able to adapt health care practices to meet the needs of
various cultures?
a
...
Culturally sensitive
c
...
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
...
What is one major advantage to the application of critical thinking?
a
...
Limitation of approaches to care
c
...
Problem prevention
ANS: D
Critical thinking results in problem prevention in designing nursing care
...
Student practical nurses are discussing the North American Nursing Diagnosis Association International
(NANDA-I) taxonomy in post conference on the acute care clinical setting
...
To initiate and identify nursing diagnosis specific to patient
b
...
To have an understanding of nursing diagnosis terminology
d
...
The licensed
practical nurse is responsible to have an understanding of nursing diagnosis terminology
...
What services are birthing centers able to provide? (Select all that apply
...
Prenatal care
b
...
Classes for new mothers

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

d
...
Family planning
ANS: A, B, C, E
Birthing centers are capable of providing full-service obstetric care, classes for new mothers, and family
planning
...

DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7
TOP: Birthing Centers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
26
...
)
a
...
Use of anesthesia
c
...
Focus on family-centered care
e
...

DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7
TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
27
...
)
a
...
Sedation of mother during labor
c
...
Lenient visiting hours
e
...
The reunion of mother and infant was delayed for several hours because of the
sedation
...

DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7
TOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28
...
Which would be included? (Select all that apply
...
Tuberculosis
b
...
Industrial accidents
d
...
Food-borne infections
ANS: A, B, D, E
The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually
transmitted diseases), food-borne infections, child abuse, and threats of suicide
...
An inservice program at a long-term care facility is reviewing the Nursing Outcomes Classification (NOC)
with nursing staff
...
Which of the following are
found to be appropriately written outcomes? (Select all that apply
...
Suction patient orally every 4 hours and as needed
...
Auscultate lung sounds every 2 hours
...
Provide Tylenol as ordered by health care provider
...
Patient states Pain has decreased after medication administration
...
Patient blood pressure recorded as 120/72 after dressing change
...

Outcomes are defined as the behaviors and feelings of the patient in response to the nursing care given
...

DIF: Cognitive Level: Application REF: Page 12-14 OBJ: 16
TOP: Nursing Outcomes Classification (NOC)
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30
...
What will these
students include when studying? (Select all that apply
...
Memorization of facts first
b
...
Relating facts to other facts
d
...
Reviewing before the test
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
...

DIF: Cognitive Level: Comprehension REF: Page 15 OBJ: 20
TOP: Critical Thinking KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment
31
...
)
a
...
Increased number of surgical births
c
...
Use of prenatal glucocorticoids
e
...

Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People
2020
...
A community health nurse is providing specialized care to patients in the home setting
...
)
a
...
Heparin therapy
c
...
Total parenteral nutrition
e
...
Family education and provision of referral are categorized as
therapeutic care
...
The nurse who is very conscientious about hand hygiene is following the concepts set out by
____________________ and ____________________
...

DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1
TOP: Handwashing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
34
...

ANS:
Theodore Roosevelt
Theodore Roosevelt called the first White House Conference in 1909
...
The nurse reviewing the specific recovery goals set out on a clinical pathway observed that two goals were
not met by their designated timeline
...

ANS:
variance
Using a clinical pathway model with goals and associated timelines, the nurse must record a negative variance
when a timeline is not met and consider a new approach or an extended timeline
...
__________________
...

ANS:
Critical thinking
Critical thinking is purposeful and goal-directed thinking as opposed to general thinking, which involves

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

random or memorized thoughts
...
A 14-year-old boy is at the pediatric clinic for a checkup
...
Stimulation of production of white cells and platelets
b
...
Increase in muscle mass and strength
d
...

DIF: Cognitive Level: Knowledge REF: Page 20-21 OBJ: 1 | 2 | 5
TOP: Male Reproductive System KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
What will the nurse indicate regulates the
production of sperm and secretion hormones?
a
...
Vas deferens
c
...
Prostate gland
ANS: A
The testes have two functions: manufacture of spermatozoa and secretion of androgens
...
The nurse is speaking with a couple trying to conceive a child
...
Infrequent sexual intercourse
b
...
The penis and testes being small
d
...

DIF: Cognitive Level: Comprehension REF: Page 22 OBJ: 3
TOP: Male Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
4
...
Perimetrium
b
...
Myometrium
d
...
It is
functional during menstruation and during the implantation of a fertilized ovum
...
A group of nursing students plans to teach a class of sixth-grade girls about menstruation
...
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
...
Early cycles are irregular and
anovulatory
...
A 10-year-old girl asks the nurse, What is the first sign of puberty? What is the correct nursing response?
a
...
Breast development
c
...
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
...
A 12-year-old female pediatric patient experienced menarche 3 months ago
...
What is the nurses best
response?
a
...

b
...

c
...

d
...

ANS: D
Early cycles are often irregular and may be anovulatory
...
In an average cycle, the flow (menses) occurs every 28 days, plus or minus
5 to 10 days
...
Which hormone initiates the maturation of the ovarian follicle?
a
...
Follicle-stimulating hormone
c
...
Luteinizing hormone
ANS: B
Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle
...
What statement indicates a woman has correct information about oogenesis?
a
...

b
...

c
...

d
...

ANS: B
Oogenesis (formation of immature ova) does not occur after fetal development
...

DIF: Cognitive Level: Comprehension REF: Page 25 OBJ: 9
TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10
...
Gynecoid
b
...
Anthropoid
d
...

DIF: Cognitive Level: Knowledge REF: Page 25 OBJ: 8
TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
11
...

What would be an important point to teach this mother?
a
...

b
...

c
...

d
...

ANS: A
Breast size does not influence the ability to secrete milk
...
For what is the decrease in estrogen and progesterone during the menstrual cycle responsible?
a
...
Ovulation
c
...
Shedding of the endometrium
ANS: D
The fall in estrogen and progesterone causes the endometrium to break down, resulting in menstruation
...
The nurse is assisting with pelvic inlet measurements on a pregnant woman
...
Diagonal conjugate
b
...
Transverse diameter
d
...

DIF: Cognitive Level: Comprehension REF: Page 26 OBJ: 8
TOP: Female Reproductive System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14
...
What statement indicates the girl needs
additional education?
a
...

b
...

c
...

d
...

ANS: C
Clots are not normally seen in menstrual discharge
...

DIF: Cognitive Level: Comprehension REF: Page 27 OBJ: 9
TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15
...
Your daughter will have her first period
...
Youll recognize puberty by the mood swings
...
The child becomes interested in the opposite sex
...
Secondary sex characteristics, such as pubic hair, appear
...
Puberty ends when mature sperm are formed in
the male and when regular menstrual cycles occur in the female
...
A nurse is planning to teach couples about the physiology of the sex act
...
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
...
Sperm must be available during that time if fertilization is to
occur
...
A newly married couple tells the nurse they would like to wait a few years before starting a family
...
My wife cant get pregnant if I withdraw before climax
...
A man can secrete semen before ejaculation
...
If we dont have intercourse very often, my wife wont get pregnant
...
It is safe to ejaculate outside the vagina
...

DIF: Cognitive Level: Comprehension REF: Page 29 OBJ: 4
TOP: Male Reproductive System KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18
...
What is the measurement in centimeters
of the obstetric conjugate?
a
...
5
b
...
5
c
...
5 to 13
d
...
5
ANS: A
The obstetric conjugate is approximately 1
...

DIF: Cognitive Level: Knowledge REF: Page 26 OBJ: 1 | 8
TOP: Obstetric Conjugate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19
...
What is true about fimbriae?
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
...
What will the nurse explain to a 12-year-old patient when describing what characterizes nocturnal
emissions?
a
...
Sexual stimulation
c
...
Association with violent dreams
ANS: C
Nocturnal emissions, also known as wet dreams, occur without sexual stimulation and contain no sperm
...

DIF: Cognitive Level: Comprehension REF: Page 21 OBJ: 2
TOP: Nocturnal Emissions KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
The nurse knows that when a patient
breastfeeds, which portions of the breast secrete milk?

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

a
...
Lobes
c
...
Alveoli
ANS: D
The alveoli secrete milk
...
Where are the secretions responsible for nourishing sperm excreted from?
a
...
Epididymis
c
...
Scrotum
ANS: C
The Cowpers gland secretions nourish the sperm
...
What signifies the end of puberty for a male?
a
...

b
...

c
...

d
...

ANS: D
Puberty ends for a male when mature sperm are formed by the testes
...
How long does sperm remain viable in the female reproductive tract?
a
...
1 day
c
...
4 days
ANS: D
Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days
...
The nurse encourages the members of a prenatal class to seriously consider breastfeeding
...
Maternal antibodies
b
...
Endorphins that soothe the infant
d
...

DIF: Cognitive Level: Comprehension REF: Page 27 OBJ: 4
TOP: Properties of Breast Milk KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26
...
What day of her cycle can
the woman anticipate ovulation?
a
...
16
c
...
20
ANS: C
Ovulation occurs when a mature ovum is released from the follicle about 14 days before the onset of the next
menstrual period
...
The nurse conducting a sex education class for junior high students describes some cultural rites
celebrating the entry to adulthood
...
)
a
...
Displays of bravery
c
...
Ritual circumcision
e
...
Ritual circumcisions and bar and bat mitzvahs are also entry rites to adulthood
...

DIF: Cognitive Level: Knowledge REF: Page 20 OBJ: 2
TOP: Rites of Passage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28
...
What information does the nurse recognize
might indicate the need for a cesarean delivery? (Select all that apply
...
History of childhood rickets
b
...
Prepregnant weight of 100 pounds
d
...
Pelvic fracture 3 years ago
ANS: A, B, E
Pelvic conditions that may predispose to a cesarean delivery are childhood rickets, pelvic fracture, and
immobile coccyx
...
What are considered to be functions of the fallopian tubes? (Select all that apply
...
Passage for sperm to meet ova
b
...
Safe environment for zygote
d
...
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
...
The nurse is providing an inservice to students beginning their obstetric clinical rotation
...
What will the nurse include? (Select all that apply
...
Two innominates
b
...
Sacrum
d
...
Coccyx
ANS: A, C, E
The bones of the pelvis are two innominates, the sacrum, and the coccyx
...
The nurse explains that testosterone is responsible for males exceeding females in which aspects? (Select
all that apply
...
Strength
b
...
Mental concentration
d
...
Agility
ANS: A, B, D DIF: Cognitive Level: Knowledge REF: Page 21
OBJ: 2 TOP: Effects of Testosterone
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...
What will the nurse
include when educating this patient on factors that affect the vaginal pH? (Select all that apply
...
Antibiotic therapy
b
...
Exercise
d
...
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
...

DIF: Cognitive Level: Application REF: Page 23 OBJ: 7
TOP: Female Reproductive Organs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

20

COMPLETION
33
...

ANS:
anteroposterior
The platypelloid pelvis is very narrow from front to back (anteroposterior)
...

DIF: Cognitive Level: Comprehension REF: Page 25 |Page 26, Figure 2-5
OBJ: 8 TOP: Platypelloid Pelvis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
34
...

ANS:
Leydig
The Leydig cells in the testes are stimulated by the FSH and LH to produce testosterone
...
The ___________ is a period of years during which the womans ability to reproduce gradually declines
...

DIF: Cognitive Level: Knowledge REF: Page 27 OBJ: 1
TOP: Female Reproduction KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36
...

ANS:
obstetrical perineum
Where the labia majora and the labia minora meet is known as the fourchette or obstetrical perineum
...

DIF: Cognitive Level: Knowledge REF: Page 22 OBJ: 1
TOP: Female Anatomy KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
37
...
Arrange the phases in order of occurrence
...
)
a
...

b
...

c
...

d
...

e
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

ANS: A, E, B, C, D
DIF: Cognitive Level: Comprehension REF: Page 29 OBJ: 2
TOP: Sexual Response KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

21

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

22

Chapter 03: Fetal Development
MULTIPLE CHOICE
1
...
22
b
...
44
d
...

DIF: Cognitive Level: Knowledge REF: Page 31 OBJ: 2
TOP: Gametogenesis KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
What will
the nurse explain to this woman?
a
...

b
...

c
...

d
...

ANS: D
When a Y-bearing sperm fertilizes an ovum, a male child is produced
...
What is the most common site for fertilization?
a
...
Outer third of the fallopian tube near the ovary
c
...
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
...
The embryo is termed a fetus at which stage of prenatal development?
a
...
4 weeks
c
...
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
...
The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the
placenta to the fetus
...
One umbilical vein
b
...
One umbilical artery
d
...

DIF: Cognitive Level: Knowledge REF: Page 39-40 OBJ: 7
TOP: Fetal Circulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6
...
Upper section of the posterior uterine wall
b
...
Inner third of the fallopian tube near the uterus
d
...

DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 3
TOP: Implantation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7
...
Amnion
b
...
Chorion
d
...

DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 4
TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8
...
Estrogen
b
...
Human placental lactogen
d
...

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6
TOP: Placenta KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9
...
What will the nurse reply?
a
...
Beginning in week 8
c
...
Beginning in week 24

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

24

ANS: A
The fetal heart begins to pump by week 3 of gestation
...
What organ does the ductus venosus shunt blood away from in fetal circulation?
a
...
Heart
c
...
Kidneys
ANS: A
Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava
...
What complication can result from untreated respiratory distress in the newborn?
a
...
Gastric dilation
c
...
Reopening of the foramen ovale
ANS: D
Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale
...
During an ultrasound, two amnions and two placentas are observed
...
Dizygotic twins
b
...
Conjoined twins
d
...

DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8
TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13
...
What does the nurse explain
is one physical characteristic present in a 25-week-old fetus?
a
...
Constant motion
c
...
Eyes that are closed
ANS: A
By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus
has definite periods of movement and sleeping
...
At what point in prenatal development do the lungs begin to produce surfactant?
a
...
20 weeks
c
...
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
...
A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test
...
Progesterone
b
...
Human chorionic gonadotropin
d
...
It is detectable in maternal blood as soon
as implantation occurs, usually 7 to 9 days after fertilization
...
When preparing to teach a class about prenatal development, the nurse would include information about
folic acid supplementation
...
Congenital heart defects
b
...
Mental retardation
d
...

DIF: Cognitive Level: Comprehension REF: Page 37 OBJ: 5
TOP: Prenatal Development KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17
...
What is considered fetal age of
viability?
a
...
20 weeks
c
...
30 weeks
ANS: B
By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of
viability)
...
The nurse is presenting a conference on gene dominance
...
10%
b
...
50%
d
...

DIF: Cognitive Level: Comprehension REF: Page 34 OBJ: 4
TOP: Dominant Traits KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19
...
What is the
most likely cause?
a
...
Inadequate blood supply
c
...
Inadequate placental nutrition
ANS: D
The single placenta may not be able to provide adequate nutrition to two fetuses
...
The school nurse is counseling a group of adolescent girls
...
They are destroyed by the acidic pH of the vagina
...
They survive up to 5 days and can cause pregnancy
...
They lose their motility in about 12 hours after intercourse
...
They are usually pushed out of the vagina by the muscular action of the vaginal wall
...

DIF: Cognitive Level: Comprehension REF: Page 33 OBJ: 3
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
Age
b
...
Body temperature
d
...

DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 3
TOP: Fertilization KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

27

22
...
1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus
b
...
2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus
d
...

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6
TOP: Fetal Circulation KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23
...
Nails
b
...
Muscles
d
...
Nails and oil glands derive from the ectoderm
...

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1
OBJ: 4 TOP: Embryonic development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
24
...

At what point of development can the couple first expect to see the sex of their child on ultrasound?
a
...
6 weeks gestational age
c
...
16 weeks gestational age
ANS: C
The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound
examination
...
A nurse is teaching a lesson on fetal development to a class of high school students and explains the
primary germ layers
...
)
a
...
Endoderm
c
...
Plastoderm
e
...

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1
OBJ: 4 TOP: Primary Germ Layers
KEY: Nursing Process Step: Implementation

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

28

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26
...
)
a
...
Impeding excessive fetal movement
c
...
Acting as a reservoir for nutrients
e
...
Although the
fetus does swallow amniotic fluid, it has no nutritional value
...
A patient at the obstetric office has just learned she is pregnant with dizygotic twins
...
)
a
...

b
...

c
...

d
...

e
...

ANS: C, D
Dizygotic twins tend to repeat in families and have separate chorions
...
Incidence increases with maternal age
...
The nurse explains that prior to fertilization each cell is reduced from 46 chromosomes to 23 chromosomes
...

ANS:
haploid
When each cell reduces its chromosomes from 46 to 23, it is called the haploid number
...
The component of development that programs the genetic code into the nucleus of the cell is
____________
...

DIF: Cognitive Level: Knowledge REF: Page 31 | Page 34
OBJ: 4 TOP: DNA KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

29

30
...

ANS:
Whartons jelly
Whartons jelly is a substance in the umbilical cord that cushions and protects the vessels
...
The normal volume of amniotic fluid is approximately _______________ mL at 37 weeks gestation
...
The volume of fluid is about 1000 mL at 37 weeks
...

DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 6
TOP: Amniotic Fluid KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...
Put a comma and space between each answer
choice (a, b, c, d, etc
...
Fetus
b
...
Embryo
d
...
Morula
ANS:
B, E, D, C, A
The development follows these stages: zygote, morula, blastocyst, embryo, and fetus
...
Put the embryonic/fetal characteristics in the correct order of occurrence from week 3 to week 36 of
gestation
...
)
a
...

b
...

c
...

d
...

e
...

ANS:
C, E, D, B, A
Primitive spinal cord and brain appear at 3 weeks
...
Skull and jaw ossify at 6
weeks
...
Subcutaneous fat is present
at 36 weeks
...
A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy
...
How would the nurse document the patients obstetric history
using the TPALM system?
a
...
Gravida 3, para 10011
c
...
Gravida 2, para 11110
ANS: C
Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para
...
A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy
...
Every 3 weeks until the 6th month, then every 2 weeks until delivery
b
...
Monthly until the 8th month
d
...

From 36 weeks until delivery, visits are weekly
...
During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present
...
Bluish or purplish discoloration of the vulva, vagina, and cervix
b
...
Darkening of the areola and breast tenderness
d
...

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4
...
What would the nurse explain as the cause of Chadwicks sign?
a
...
Progesterone action on the breasts
c
...
Vascular congestion in the pelvic area
ANS: D
Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area
...
The nurse has explained physiological changes that occur during pregnancy
...
Blood pressure goes up toward the end of pregnancy
...
My breathing will get deeper and a little faster
...
Ill notice a decreased pigmentation in my skin
...
There will be a curvature in the upper spine area
...

DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 7 | 13
TOP: Normal Physiological Changes in Pregnancy
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6
...
What is this womans
expected delivery date using Ngeles rule?
a
...
May 5, 2014
c
...
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
...
During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler
device
...
4 weeks
b
...
10 weeks
d
...

DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 3 | 7
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
...
What is the
nurses first action?
a
...

b
...

c
...

d
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

33

ANS: D
The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min
...
The FHR drops in the late stages of pregnancy
...
A womans prepregnant weight is determined to be average for her height
...
10 to 20 pounds
b
...
25 to 35 pounds
d
...

DIF: Cognitive Level: Knowledge REF: Page 57 OBJ: 8
TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
What dietary adjustments could the nurse recommend?
a
...

b
...

c
...

d
...

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
...
A pregnant woman is experiencing nausea in the early morning
...
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
...

DIF: Cognitive Level: Application REF: Page 65, Table 4-6
OBJ: 10 TOP: Common Discomforts in Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12
...
What is the nurses
initial action?
a
...

b
...

c
...

d
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

34

ANS: C
The marked weight gain may be an indication of gestational hypertension
...

DIF: Cognitive Level: Application REF: Page 53 OBJ: 4
TOP: Gestational Hypertension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13
...
The nurse
replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development
...
Fried fish
b
...
Red meat
d
...
Frying fish negatively alters the
DHA
...
The nurse encourages adequate intake of folic acid for women of childbearing age before and during
pregnancy
...
Structural heart defects
b
...
Limb deformities
d
...

DIF: Cognitive Level: Knowledge REF: Page 45 | Page 61
OBJ: 8 TOP: Nutrition for Pregnancy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
15
...
The nurse recognizes which as a positive
sign of pregnancy?
a
...
Uterine enlargement
c
...
Fetal heartbeat
ANS: D
Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by
ultrasound, and fetal movements felt by the examiner
...
At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age
can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope?
a
...
12 weeks
c
...
24 weeks
ANS: C
The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy
...
A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the
nurses best response?
a
...

b
...

c
...

d
...

ANS: A
Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation
...
A pregnant woman inquires about exercising during pregnancy
...
Exercise elevates the mothers temperature and improves fetal circulation
...
Exercise increases catecholamines, which can prevent preterm labor
...
A regular schedule of moderate exercise during pregnancy is beneficial
...
Pregnant women should limit water intake during exercise
...

DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 9 | 13
TOP: Exercise During Pregnancy KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
19
...
How does the need for prenatal care and
counseling for adolescents different from other age populations?
a
...

b
...

c
...

d
...

ANS: A
The pregnant adolescent must cope with two of lifes most stress-laden transitions simultaneously: adolescence
and parenthood
...
At what age is a woman who becomes pregnant for the first time described as an elderly primip?

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

36

a
...
After 28 years old
c
...
After 35 years old
ANS: D
A woman over the age of 35 who becomes pregnant for the first time is described as an elderly primip
...
The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy
...
Chadwicks
b
...
McDonalds
d
...

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 1 | 6 | 7
TOP: Goodells Sign KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physical Adaptation
22
...
Given this information, what lab test can the nurse anticipate the physician will order?
a
...
Pap test
c
...
Hemoglobin electrophoresis
ANS: D
Hemoglobin electrophoresis identifies presence of sickle cell trait or disease (in women of African or
Mediterranean descent)
...

DIF: Cognitive Level: Comprehension REF: Page 46, Table 4-1
OBJ: 3 TOP: Prenatal laboratory tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
23
...
Prenatal lab work indicates she is not immune
to the rubella virus
...
Provide the rubella vaccine as ordered by the physician immediately
...
Inform the woman she should receive the vaccine in the hospital after delivery
...
Hold all immunizations until 1 month postpartum
...
Encourage the patient to decide whether or not to get the rubella vaccine prenatally
...
A woman should be instructed to avoid pregnancy for
at least 1 month following rubella immunization
...

DIF: Cognitive Level: Application REF: Page 72 OBJ: 4
TOP: Immunizations KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
24
...
What does the nurse

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

37

explain as the most likely cause of this symptom?
a
...
Gestational diabetes
c
...
Malnutrition
ANS: A
Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the
woman lies on her back
...

DIF: Cognitive Level: Comprehension REF: Page 53 OBJ: 7
TOP: Physiological Changes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care
MULTIPLE RESPONSE
25
...
What
would the nurse recommend that the patient do during the flight? (Select all that apply
...
Wear tight-fitting clothing to promote venous return
...
Eat a large meal before boarding the flight
...
Request a seat with greater leg room
...
Drink at least 4 ounces of water every hour
...
Get up and walk around the plane frequently
...
Adequate
hydration, frequent position changes, and movement decrease the risk
...
The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax
...
)
a
...
Joint instability
c
...
Back pain
e
...
The other discomforts are
related to the enlarging uterus with its attendant weight
...
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
b
...
Spends leisure time with his friends
d
...
Helped select a crib
ANS: B, D, E
Active planning for an infant is an indication of the acceptance stage
...

DIF: Cognitive Level: Comprehension REF: Page 68-69 OBJ: 11
TOP: Stages of Fatherhood KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28
...
)
a
...

b
...

c
...

d
...

e
...

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
...
The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy?
(Select all that apply
...
Showing off her sonogram photos
b
...
Emotional and labile mood
d
...
Fatigue
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
...

DIF: Cognitive Level: Comprehension REF: Page 67 OBJ: 11
TOP: Behaviors of First Trimester KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
30
...

ANS:
gynecological
Gynecological age is a term that refers to the number of years between the starting of the menses and the date
of conception
...
The nurse reminds the prenatal patient that she should add ________ kcal to her daily intake to nourish the
fetus
...

DIF: Cognitive Level: Comprehension REF: Page 59 OBJ: 8
TOP: Nutrition During Pregnancy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...
The nurse assesses this behavior as
__________
...

DIF: Cognitive Level: Comprehension REF: Page 61 OBJ: 8
TOP: Pica KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33
...

ANS:
Leopolds
Leopolds maneuver assesses the position and the presentation of the fetus by palpation
...
Fathers go through phases similar to the expectant mother
...
Put a comma and space between each answer choice (a, b, c, d, etc
...
Focus phase
b
...
Adjustment phase
ANS:
B, C, A
For fathers, the announcement phase begins when pregnancy is confirmed
...
The third phase of the fathers response is the focus phase, in which active
plans for participation in the labor process, birth, and change in lifestyle result in the partner feeling like a
father
...
A pregnant patient tells the nurse that she has been nauseated and vomiting
...
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
...
Dehydration impairs the perfusion to the placenta
...
A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping
...
Cervical dilation is noted on examination
...
Inevitable abortion
b
...
Complete abortion
d
...

DIF: Cognitive Level: Comprehension REF: Page 84, Table 5-2 | Page 82, Figure 5-2
OBJ: 4 TOP: Incomplete Abortion
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3
...
What is the most appropriate statement by the nurse?
a
...

b
...
You can try to conceive on your next cycle
...
Im here if you need to talk
...
You are young and strong
...

ANS: C
An effective technique when communicating with a woman experiencing pregnancy loss is to say, Im here if
you need to talk
...

DIF: Cognitive Level: Application REF: Page 85 OBJ: 4
TOP: Dilation and Evacuation (D&E) KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4
...
An ectopic pregnancy is confirmed by ultrasound
...
The chorionic villi develop vesicles within the uterus
...
The placenta develops in the lower part of the uterus
...
The fetus dies in the uterus during the first half of the pregnancy
...
The embryo is implanted in the fallopian tube
...

DIF: Cognitive Level: Comprehension REF: Page 86 OBJ: 4
TOP: Ectopic Pregnancy KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5
...
What does the nurse understand best describes this condition?
a
...
Marginal placenta previa
c
...
Total placenta previa
ANS: D
A total placenta previa describes a condition in which the placenta completely covers the cervical opening
...
What symptom presented by a pregnant women is indicative of abruptio placentae?
a
...
Uterine irritability with contractions
c
...
Premature rupture of membranes
ANS: C
Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae
...
What situation would concern the nurse about the presence of Rh incompatibility?
a
...
Rh-positive mother, Rh-negative fetus
c
...
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
...
A primigravida in her first trimester is Rh negative
...
Rh immune globulin during labor
b
...
Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant
d
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

42

DIF: Cognitive Level: Comprehension REF: Page 95 OBJ: 4
TOP: Rh Incompatibility KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9
...
What does the nurse recognize these factors highly suggest?
a
...
Abruptio placentae
c
...
Diabetes mellitus
ANS: D
Large (macrosomic) infants over 9 pounds are linked to gestational diabetes
...
A nurse is providing prenatal education
...
Placental hormones increase the resistance of cells to insulin
...
Insulin cells cannot meet the bodys demands as the womans weight increases
...
There is a decreased production of insulin during pregnancy
...
The speed of insulin breakdown is decreased during pregnancy
...

DIF: Cognitive Level: Knowledge REF: Page 96 OBJ: 5
TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 97 | Page 100
OBJ: 5 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
12
...
She is afraid that
her infant will also contract hepatitis B
...
The infant will be given a single dose of hepatitis immune globulin after birth
...
The infant will be able to use the antibodies from the immunizations given to the patient before delivery
...
The infant will not have hepatitis B because the virus does not pass through the placental barrier
...
The infant will be immune to hepatitis B because of the mothers infection
...
Immunization is not recommended for women who are pregnant
...
What will the nurse begin with when asking a patient about drug use during a prenatal history?
a
...
Do you ever use prescription or street drugs?
c
...
We need to know if you take drugs so we can help your baby
...

DIF: Cognitive Level: Application REF: Page 108 | Page 110
OBJ: 6 TOP: Interviewing Relative to Drug Use
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14
...
What is the first sign of fluid
retention suggestive of this complication?
a
...
Facial swelling
c
...
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
...
A patient with gestational hypertension is exhibiting all of the signs below
...
Diarrhea
b
...
Blurred vision
d
...

DIF: Cognitive Level: Application REF: Page 91 OBJ: 4
TOP: Hypertension KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16
...
What need would the home
health nurse make the first priority?
a
...
Balanced nutrition
c
...
Instruction about the effect of diuretics
ANS: A
Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and
enhancing fetal oxygenation
...
The nurse is caring for a pregnant woman diagnosed with preeclampsia
...
To prevent convulsions
b
...
To increase reflex irritability
d
...

DIF: Cognitive Level: Knowledge REF: Page 92-93 OBJ: 4
TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18
...
What
is the most appropriate nursing intervention?
a
...

b
...

c
...

d
...

ANS: A
Excessive magnesium sulfate may cause respiratory depression
...
What drug will the nurse plan to have available for immediate IV administration whenever magnesium
sulfate is administered to a maternity patient?
a
...
Oxytocin
c
...
Hydralazine (Apresoline)
ANS: C
Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a
woman receives magnesium sulfate
...
A woman who is 35 weeks pregnant has a total placenta previa
...
Yes, you can deliver vaginally until 36 weeks
...
A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done
...
A cesarean section is performed when the mother has a total placenta previa
...
There is no reason why you cannot have a vaginal delivery
...

DIF: Cognitive Level: Application REF: Page 90 OBJ: 4

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45

TOP: Placenta Previa KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21
...

What can result from maternal rubella during pregnancy?
a
...
Mental retardation
c
...
Limb deformities
ANS: B
Rubella can have devastating effects on the developing fetus
...

DIF: Cognitive Level: Knowledge REF: Page 104 OBJ: 5
TOP: Rubella KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22
...
Frequency and urgency of urination
b
...
Burning sensation when voiding
d
...
Signs and symptoms include high fever, chills,
flank pain or tenderness, nausea, and vomiting
...
The nurse is caring for a prenatal patient diagnosed with a placenta previa
...
Flat on her back with knees flexed to help prevent hemorrhage
b
...
In the semi-Fowlers position to prevent supine hypotension
d
...
This position not
only reduces stress on the placenta but also reduces the possibility of supine hypotension
...
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
...
After delivery your doctor will prescribe oral hypoglycemic medication to control your disease
...

b
...
After a while those insulin injections wont seem so bad
...
It will most likely resolve 6 weeks or so after the baby is born
...

DIF: Cognitive Level: Application REF: Page 97 OBJ: 4

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TOP: GDM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
25
...
What
intervention will the nurse implement before this diagnostic test?
a
...

b
...

c
...

d
...

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)
...
The nurse is caring for a macrosomic newborn of a diabetic patient
...
)
a
...
Diarrhea
c
...
Muscle tremors
e
...
This insulin
may cause hypoglycemia in the infant after it is no longer exposed to the mothers blood
...
The nurse educates prenatal patients about the threat of TORCH infections
...
)
a
...
Toxemia
c
...
Rubella
e
...

DIF: Cognitive Level: Knowledge REF: Page 103 OBJ: 6
TOP: TORCH Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
28
...
)
a
...
Financial pressures
c
...
Frustration with activity restriction
e
...

DIF: Cognitive Level: Comprehension REF: Page 112 OBJ: 8
TOP: Impact of High-Risk Pregnancies KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
29
...
What
should the ED nurse offer the patient? (Select all that apply
...
Privacy
b
...
Materials about support groups
d
...
A warm beverage
ANS: A, B, C, D
The patient should be offered privacy, an opportunity to hold the infant, support group information, and a
memento
...

DIF: Cognitive Level: Application REF: Page 112 OBJ: 8
TOP: Stillborn Infant KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
30
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, D, E
Calcium, bran, and milk interfere with the absorption of iron
...

DIF: Cognitive Level: Application REF: Page 102 OBJ: 5
TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
31
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, D
Vaginal organisms reach the placenta through the cervix
...
The weak musculature of the lower segment of the uterus will cause
postpartum hemorrhage rather than infection
...
The nurse is obtaining history and physical information on a new patient attending her first prenatal visit
...
What complications
related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply
...
Gestational diabetes
b
...
Hypertension
d
...
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
...
A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is
battered by her husband
...
What nursing
actions are appropriate for the nurse to implement? (Select all that apply
...
Tell the husband that authorities will be notified immediately
...
Provide privacy for the assessment
...
Determine if children are being hurt
...
Communicate in a non-judgmental way
...
Determine factors that increase the risk of injury
...
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
...
It is vital that the abuser not find out that the woman has reported the abuse or that she
intends to leave
...
The nurse cautions that the consumption of as few as ________ alcoholic drink(s) during pregnancy can
lead to the loss of fetal brain cells
...
A drink is defined as 12 oz of beer, 5 oz of wine, or 1
...

DIF: Cognitive Level: Comprehension REF: Page 110, Nursing Tip
OBJ: 5 TOP: Fetal Alcohol Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
35
...

ANS:
cerclage

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Cerclage is the procedure that sutures the cervix closed to prevent its opening when the fetus presses against it
...
________________________ ________________________ is the leading cause of perinatal infections that
have a high mortality rate
...

The organism can be found in the womans rectum, vagina, cervix, throat, or skin
...
A(n) _________________________________ consists of a group of five fetal assessments: fetal heart rate
and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand),
and volume of amniotic fluid
...

DIF: Cognitive Level: Knowledge REF: Page 81, Table 5-1
OBJ: 2 TOP: Diagnostic tests
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Heath Promotion and Maintenance: Prenatal Care

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

50

Chapter 06: Nursing Care of Mother and Infant During Labor and Birth
MULTIPLE CHOICE
1
...
How long the patient states the contractions last
b
...
The time between the beginning and the end of one contraction
d
...

DIF: Cognitive Level: Comprehension REF: Page 120 OBJ: 9
TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2
...
The laboring woman needs to rest
...
The uterine muscles fatigue without relaxation
...
The contractions can interfere with fetal oxygenation
...
The infant progresses toward delivery at these times
...
During the interval
between contractions, the placenta refills with oxygenated blood for the fetus
...
What contraction duration and interval does the nurse recognize could result in fetal compromise?
a
...
Duration shorter than 90 seconds, interval longer than 120 seconds
c
...
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
...
Vaginal examination reveals the presenting part is the infants head, which is well flexed on the chest
...
Vertex
b
...
Brow
d
...
The head is fully flexed on the chest
...
What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?
a
...
Fetal maturity
c
...
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
...
It is determined that the presenting part of the fetus is the buttocks
...
How would the nurse record this presentation?
a
...
Frank breech
c
...
Buttocks presentation
ANS: B
When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the
shoulders
...
At a prenatal visit, a primigravida asks the nurse how she will know her labor has started
...
Contractions that are relieved by walking
b
...
A decrease in vaginal discharge
d
...

DIF: Cognitive Level: Application REF: Page 131, Table 6-2
OBJ: 7 TOP: Initiation of Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8
...
What is the nurses most informative response?
a
...
When contractions are 10 minutes apart
c
...
When abdominal or groin discomfort occurs
ANS: C
Ruptured membranes are an indication that the woman should go to the hospital or birthing center
...
The nurse is caring for a woman in the first 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
...

DIF: Cognitive Level: Comprehension REF: Page 144, Table 6-6
OBJ: 6 TOP: First Stage of Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
When she begins cursing at her birthing
coach and the nurse, what does the nurse assess as the most likely explanation for the womans change in
behavior?
a
...

b
...

c
...

d
...

ANS: A
If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage
of labor
...
What is the function of contractions during the second stage of labor?
a
...
Dilate and efface the cervix
c
...
Separate the placenta from the uterine wall
ANS: C
The contractions push the infant out of the mothers body as the second stage of labor ends with the birth of the
infant
...
What marks the end of the third stage of labor?
a
...
Expulsion of the placenta and membranes
c
...
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
...
Why should the nurse encourage the mother to void during the fourth stage of labor?
a
...

b
...

c
...

d
...

ANS: D
A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and
interferes with contractions
...
The nurse observes the patient bearing down with contractions and crying out, The baby is coming! What
is the best nursing intervention?
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
...
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
...
A well-oxygenated fetus
b
...
Compression of the fetal head
d
...

DIF: Cognitive Level: Analysis REF: Page 135 OBJ: 9
TOP: Fetal Accelerations KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16
...
At the beginning of a contraction, hold your breath and push for 10 seconds
...
Take a deep breath and push between contractions
...
Begin pushing when a contraction starts and continue for the duration of the contraction
...
At the beginning of a contraction, take two deep breaths and push with the second exhalation
...


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DIF: Cognitive Level: Application REF: Page 142 OBJ: 9
TOP: Instructions for Pushing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17
...
Monitor the frequency and intensity of contractions
...
Provide comfort measures
...
Assess for hemorrhage
...
Promote bonding
...

DIF: Cognitive Level: Comprehension REF: Page 147 OBJ: 9
TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18
...
What is the most
appropriate nursing action?
a
...

b
...

c
...

d
...

ANS: A
Increased lochia may indicate hemorrhage
...
One pad an hour is an
acceptable rate for immediate postdelivery
...
While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate
with uterine contractions
...
Stop the oxytocin infusion
...
Increase the intravenous flow rate
...
Reposition the woman on her side
...
Start oxygen via nasal cannula
...
If the decelerations
continue, then oxygen should be administered and/or the flow rate of oxygen should be increased
...
How should the nurse intervene to relieve perineal bruising and edema following delivery?
a
...

b
...

c
...

d
...

ANS: A
An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hours followed by a
warm pack after the first 12 to 24 hours after delivery
...
At 1 and 5 minutes of life, a newborns Apgar score is 9
...
The newborn will require resuscitation
...
The newborn may have physical disabilities
...
The newborn will have above average intelligence
...
The newborn is in stable condition
...
Five categories are
evaluated on a scale from 0 to 2, with the highest score being 10
...

DIF: Cognitive Level: Comprehension REF: Page 151-152, Table 6-7
OBJ: 10 TOP: Care of the Infant After Birth
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22
...
Fetal head is above the ischial spines
...
Fetal head is below the ischial spines
...
Fetal head is engaged in the mothers pelvis
...
Fetal head is visible at the perineum
...
It is estimated in centimeters from the level of
the ischial spines
...

DIF: Cognitive Level: Comprehension REF: Page 126 | Page 128, Figure 6-10
OBJ: 1 TOP: Mechanisms of Labor
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
23
...
What is the most
appropriate nursing diagnosis?
a
...

b
...

c
...

d
...

ANS: D
In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage
...
The nurse is caring for a patient who is not certain if she is in true labor
...
By offering the patient warm fluids to drink
b
...
By seating the patient upright in a straight-back chair
d
...

DIF: Cognitive Level: Application REF: Page 131, Table 6-2
OBJ: 5 | 7 TOP: Differentiating Between True and False Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
25
...
Reposition the patient to supine
b
...
Increase oxygen to 10 L/minute
d
...
IV fluids are increased to
increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine
hypotension
...
What is the nurse primarily concerned about maintaining in the initial care of the newborn?
a
...
Feeding schedule
c
...
Parental bonding
ANS: C
Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low
...

DIF: Cognitive Level: Comprehension REF: Page 150 OBJ: 10
TOP: Thermoregulation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
27
...
What is the primary concern regarding complications for this patient during labor
and birth?
a
...
Placental abruption
c
...
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
...
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
...
The physician performs an amniotomy on a laboring woman
...
Fetal heart rate
b
...
Maternal blood pressure

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d
...
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
...
Maternal blood pressure and deep tendon reflexes are not appropriate assessments
following rupture of membranes
...
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
...
The husband is in attendance but not as a participant
...
If a
male is in attendance, then the husband will remain in the room as long as the male is there
...
What are the advantages of a freestanding birth center? (Select all that apply
...
Home-like setting
b
...
Lower costs
d
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 116 OBJ: 3
TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31
...
)
a
...
Uteroplacental insufficiency
c
...
Cord compression
e
...
Prolonged

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58

decelerations indicate cord compression and early decelerations indicate head compressions
...
A pregnant woman arrives at the emergency department (ED) and reports she is in labor
...
What signs and symptoms
would lead the nurse to suspect false (prodromal) labor? (Select all that apply
...
Leaking of vaginal fluid
b
...
Pink spotting
d
...
Cervix thick and not effaced
ANS: D, E
Painless tightening of abdominal muscles (Braxton-Hicks contractions) and cervix thick and not effaced lend
to the determination of false (prodromal) labor
...
Contractions that intensify with ambulation and pink spotting (bloody show) are
signs of true labor
...
After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the infant as
ROA; this means that the infants head is _________ __________ _________
...

DIF: Cognitive Level: Knowledge REF: Page 125, Box 6-1
OBJ: 9 TOP: Fetal Position
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
34
...

ANS:
powers, passenger, passage, psyche
The four interrelated components of the process of labor and birth, called the four Ps, are powers, passenger,
passage, and psyche
...
After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for ________
minute(s)
...

DIF: Cognitive Level: Application REF: Page 137 OBJ: 9
TOP: Assessment After Membrane Rupture
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36
...

ANS:
Leopolds maneuver
The nurse may assist the health care provider in determining the fetal position and presentation by abdominal
palpations called Leopolds maneuver
...
A nursing student is observing prenatal exams in the office setting
...
The student interprets this as a ____________________ presentation
...
This is a breech presentation
...
Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor
...
Put a comma and space between each answer choice (a, b, c, d, etc
...
Extension
b
...
Descent
d
...
Expulsion
f
...
External rotation
ANS:
C, B, D, F, A, G, E
The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into
the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled
...
A nurse is teaching a childbirth preparation class
...
What statement is accurate about a patients expression of pain?
a
...

b
...

c
...

d
...

ANS: C
Culture influences how women feel about birth and what is an acceptable response to pain
...
What chemical substance(s) produced in the body acts as a natural pain reliever?
a
...
Morphine
c
...
Atropine
ANS: A
Endorphins are natural body substances that are similar to morphine and may explain why laboring women
need smaller doses of analgesia
...
A nurse instructs a womans labor coach to comfort her by firmly pressing on her lower back
...
Sacral pressure
b
...
Effleurage
d
...

DIF: Cognitive Level: Knowledge REF: Page 160, Box 7-1
OBJ: 6 TOP: Nonpharmacological Pain Management
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
4
...
What will the nurse instruct the woman to do during the
contraction?
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
...
Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth
...
Hypertension
b
...
Anoxia
d
...

DIF: Cognitive Level: Comprehension REF: Page 164, 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
...
Help her breathe into her cupped hands
...
Place her flat on her back
...
Initiate oxygen at 2 liters via mask
...
Notify the doctor
...
All of these techniques decrease PCO2
...
A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief
...
It can cause medication given at later stages to be ineffective
...
It will have no complications for the mother or infant
...
It may result in respiratory depression to the newborn
...
It will speed up labor and increase pain
...

DIF: Cognitive Level: Comprehension REF: Page 164-165
OBJ: 7 TOP: Opioids KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
8
...
Offer warm liquids to the patient
...
Encourage the patient to pant
...
Engage the patient in conversation
...
Assist the patient to the knee-chest position
...
It would not be helpful to offer fluids or to attempt
conversation during contractions
...

DIF: Cognitive Level: Application REF: Page 163 OBJ: 4
TOP: Panting KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9
...
The nurse reminds the patient
that food and fluids need to be restricted for several hours prior to delivery
...
Nausea and vomiting
b
...
Abdominal cramping
d
...

DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2
OBJ: 7 TOP: General Anesthesia
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
10
...
Bladder for distention
b
...
Sensation in the lower extremities
d
...
Bladder assessment is also
important but not an initial assessment
...
A woman in labor has had an epidural block for pain relief
...
Reduced fetal heart rate
b
...
Sudden leg cramps
d
...
The patient may have to be catheterized
...
Which narcotic antagonist is used to reverse narcotic-induced respiratory depression?
a
...
Phenobarbital
c
...
Nitrous oxide
ANS: C
Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics
...
The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery
...
Restrict oral fluids
...
Keep legs flexed
...
Walk with assistance as soon as possible
...
Lie flat for several hours
...

DIF: Cognitive Level: Application REF: Page 166, Table 7-2
OBJ: 7 TOP: Subarachnoid Block
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14
...
What statement by the woman indicates a
need for further explanation about the pudendal block?
a
...
Can I get the pudendal block now?
b
...

c
...

d
...

ANS: A
The pudendal block does not block pain from contractions and is given just before birth
...
An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart
...
She is crying loudly and shouting, Please give me something
for the pain
...
Pain related to uterine contractions
b
...
Ineffective coping related to inadequate preparation for labor
d
...

DIF: Cognitive Level: Analysis REF: Page 170, Nursing Care Plan 7-1
OBJ: 3 TOP: Pain as a Priority
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
16
...
Slow abdominal breathing
b
...
Listening to music
d
...
Massage is a technique that stimulates large-diameter
fibers and closes the gate
...
When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for
delivery
...
Abnormal clotting
b
...
History of migraine headaches
d
...

DIF: Cognitive Level: Comprehension REF: Page 166, Table 7-2 | Page 168
OBJ: 7 TOP: Epidural Block
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18
...
What may
premature bearing down cause?
a
...
Cervical laceration
c
...
Compression of the cord
ANS: B
Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix
...
What is the Dick-Read method of childbirth preparation based on?
a
...
Relaxation techniques
c
...
Deep massage
ANS: B
The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor
...
The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline
respiratory rate is 22 breaths per minute
...
9
b
...
15
d
...


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DIF: Cognitive Level: Comprehension REF: Page 160, Box 7-1
OBJ: 5 TOP: Lamaze Method
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21
...
Tolerance
b
...
Level
d
...
Thresholds are different for each
individual
...
The nurse is caring for a laboring patient who is not reporting pain
...
Frequently asking for ice chips
b
...
Changing positions in bed
d
...

DIF: Cognitive Level: Comprehension REF: Page 164 OBJ: 3
TOP: Nonverbal Pain Expressing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
23
...
What is the nurses
best response to explain the frequent blood pressure assessments?
a
...

b
...

c
...

d
...

ANS: D
The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading
to fetal hypoxia
...
A laboring patient requests hot and cold applications be applied to her abdomen for pain control
...
By increasing endorphin production
b
...
By producing increasing pain tolerance
d
...
It supports several
nonpharmacological methods of pain control
...
However, the stimulation of large-diameter nerve fibers temporarily interferes with the
conduction of impulses through small-diameter fibers
...

DIF: Cognitive Level: Comprehension REF: Page 159, 162
OBJ: 3 TOP: Nonpharmacological Pain Relief
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
25
...
What will the nurse anticipate?
a
...
Severe lower back pain
c
...
Nausea
ANS: B
If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mothers sacrum,
resulting in persistent and poorly relieved back pain (back labor)
...

DIF: Cognitive Level: Application REF: Page 161 OBJ: 3
TOP: Maternal Condition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
26
...
)
a
...
Breastfeeding
c
...
Sources of financial aid
e
...
Yoga and financial information are not traditional content for prenatal instruction
...
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
...
First stage breathing
b
...
Fourth stage breathing
d
...
Patterned paced breathing
ANS: A, B, D, E
First stage breathing includes the techniques of modified pace breathing and patterned paced breathing, which
are types of abdominal breathing techniques
...
The fourth stage of labor is the womans recovery stage and does not require a
breathing technique
...
How does the pain of childbirth differ from other types of pain? (Select all that apply
...
Childbirth pain is part of a normal process
...
Childbirth pain seldom needs narcotic relief
...
Position changes relieve pain and facilitate delivery
...
Childbirth pain declines following birth
...
Childbirth pain is self-limited
...
Childbirth
pain requires pharmacological management with narcotics in many cases
...
Which are nonpharmacological forms of pain relief? (Select all that apply
...
Skin stimulation
b
...
Breathing techniques
d
...
Yoga
ANS: A, B, C
Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain
control
...

DIF: Cognitive Level: Knowledge REF: Page 160, Box 7-1 | Page 162
OBJ: 5 TOP: Nonpharmacological Pain Control
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30
...
)
a
...
Pelvic rock
c
...
Sit-ups
e
...
Leg lifts and sit-ups are not beneficial because they both
increase intraabdominal pressure
...
The nurse is providing a conference on nonpharmacological pain control methods
...
)
a
...

b
...

c
...

d
...


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e
...

ANS: B, C, D, E
All the options mentioned are benefits of nonpharmacological pain control methods with the exception of
sedating the mother
...
The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery
...
What interventions are
appropriate for the nurse to implement related to this diagnosis? (Select all that apply
...
Assess leg movement and sensation before ambulating
...
Administer antibiotic as ordered
...
Observe for signs of impending birth
...
Provide sacral pressure as needed
...
Assess fetal position frequently
...

DIF: Cognitive Level: Application REF: Page 172 OBJ: 8
TOP: Epidural Anesthesia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
33
...
What will the nurse include in the educational plan? (Select all that apply
...
Onset is slow
...
Duration is short
...
Administration is by mouth
...
No known side effects
...
It is not the same drug as sufentanil
...
Fentanyl, sufentanil, and alfentanil are not the same
drugs
...
It is not administered by mouth
...
The amount of pain a person is willing to endure is referred to as ______________ ______________
...
Pain threshold is the point at which pain is
perceived
...

DIF: Cognitive Level: Knowledge REF: Page 159 OBJ: 1
TOP: Pain Tolerance KEY: Nursing Process Step: Implementation

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69

MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35
...

ANS:
effleurage
Effleurage stimulates the large-diameter fibers and blocks the pain impulses from the small-diameter fibers
...
The ______________ ___________, also called the psychoprophylactic method, is the basis of most
childbirth preparation classes in the United States
...

DIF: Cognitive Level: Knowledge REF: Page 161 OBJ: 5
TOP: Childbirth Preparation KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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Chapter 08: Nursing Care of Women with Complications During Labor
and Birth
MULTIPLE CHOICE
1
...
Fetal heart rate is regular at 154 beats/min
...
Amniotic fluid is clear with flecks of vernix
...
Amniotic fluid is watery and pale green
...
Maternal temperature is 37
...

ANS: C
Amniotic fluid should be clear
...

DIF: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Obstetric ProceduresAmniotomy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
2
...
What is the nurses initial action?
a
...

b
...

c
...

d
...

ANS: A
Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur
...
What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
a
...
Cold pack to the perineum
c
...
Elevation of hips to prevent edema
ANS: B
Ice is applied to the perineum to reduce bruising and edema
...
After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but
contractions are becoming shorter and less frequent
...
Normal
b
...
Hypertonic
d
...

DIF: Cognitive Level: Comprehension REF: Page 187, Box 8-2
OBJ: 5 TOP: Abnormal Labor
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5
...
What action by the physician will the nurse anticipate?
a
...

b
...

c
...

d
...

ANS: A
Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the
membranes are intact
...
An infant is delivered with the use of forceps
...
Loss of hair from contact with forceps
b
...
Facial asymmetry
d
...

DIF: Cognitive Level: Application REF: Page 181 OBJ: 3
TOP: Obstetric ProceduresForceps Delivery
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7
...
The
nurse responds, This condition will resolve itself in a few days
...
Prolonged pressure against the partially dilated cervix
b
...
Pressure of the forceps during delivery
d
...

DIF: Cognitive Level: Comprehension REF: Page 181 OBJ: 2
TOP: Chignon KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8
...
He said I was a 4
...
6
b
...
10
d
...
A minimum score of 6 is
recommended by the American Congress of Obstetricians and Gynecologists (ACOG)
...
A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP)
...
Prone with legs supported and give her a back massage
b
...
Standing with support
d
...

DIF: Cognitive Level: Application REF: Page 189-190
OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
10
...
The panicked woman begs the nurse, Please give me something
...
Get an order for an intravenous narcotic
...
Notify the anesthesiologist for an epidural block
...
Stay and breathe with her during contractions
...
Tell her to bear with it because she is close to delivery
...

DIF: Cognitive Level: Application REF: Page 191-192
OBJ: 6 TOP: Abnormal Labor
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance
11
...
What complication should the nurse closely assess for with this patient?
a
...
Hemorrhage
c
...
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
...
The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor
...
Maternal tachycardia

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b
...
Fetal bradycardia
d
...

DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6
TOP: Preterm Labor KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13
...
After my shower in the morning, I do the laundry and straighten up the house; then I rest
...
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
...
I have a 2-year-old to care for, but I try to rest as much as I can
...
I get really bored at home, so I go to the shopping mall for just a little while
...
The nurse can help the woman identify
ways to organize necessary activities and maximize rest
...
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
...
The fundus is not assessed until the second postoperative day
...
The fundus is assessed by walking fingers from the side of the uterus to the midline
...
The fundus is assessed only if large clots appear in lochia
...
The fundus is assessed only once every shift
...

DIF: Cognitive Level: Comprehension REF: Page 183 OBJ: 4
TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15
...
How would the nurse
position the woman to prevent compression of a prolapsed cord?
a
...
On her left side with a pillow placed between her legs
c
...
Supine with her legs elevated and bent at the knee
ANS: C
The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord
...
Several hours after delivery the nurse finds a woman crying
...
Instead I needed an emergency C-section
...
Anxiety related to the development of postpartum complications
b
...
Risk for ineffective parenting related to emergency cesarean section
d
...
They may
feel grief, guilt, or anger because the expected course of birth did not occur
...
A pregnant womans membranes ruptured prematurely at 34 weeks
...
What would the nurse planning discharge instruction teach the woman to do?
a
...

b
...
8 C (100 F)
...
Massage her breasts to promote uterine relaxation
...
Rest in a side-lying Trendelenburg position with hips elevated
...
The woman should monitor her temperature
and report a temperature greater than 37
...

DIF: Cognitive Level: Application REF: Page 192 OBJ: 6
TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18
...
What side
effect should the nurse inform the patient that she might experience?
a
...
Headache
c
...
Urinary frequency
ANS: C
Magnesium sulfate is the drug of choice for initiating therapy to stop labor
...

DIF: Cognitive Level: Knowledge REF: Page 193 OBJ: 6
TOP: Preterm Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
19
...
How can anxiety affect labor?
a
...
By reducing blood flow to the uterus
c
...
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
...
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
...
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
...
This should be
reported immediately
...
What does the nurse explain is used to soften the cervix with a cervical ripening agent?
a
...
Intravenous oxytocin
c
...
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
...
The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids
...
Prevent infection
...
Increase fetal lung maturity
...
Increase blood flow from placenta
...
Relax the cervix
...

DIF: Cognitive Level: Comprehension REF: Page 193 OBJ: 6
TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23
...

Which laboring patient should the nurse attend to first?
a
...
25-year-old multigravida with history of previous cesarean section
c
...
16-year-old primigravida with a twin pregnancy
ANS: C
A precipitate birth is completed in less than 3 hours
...
Contractions may be frequent and intense, often from
the onset
...
Fetal breech presentation, history of cesarean section, and multifetal
pregnancy have associated risk factors, but not as immediate as precipitate birth
...
The nurse is caring for a patient diagnosed with hypotonic labor dysfunction
...
Elevated uterine resting tone
b
...
Implementation of fluid restriction
d
...
With hypotonic labor uterine resting tone is decreased and IV fluids are increased
...

DIF: Cognitive Level: Comprehension REF: Page 187 OBJ: 5 | 6
TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
25
...
)
a
...
8 F)
b
...
Flecks of vernix in the amniotic fluid
d
...
Edematous labia
ANS: B
Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation
...

DIF: Cognitive Level: Application REF: Page 176 OBJ: 3
TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26
...
)
a
...
Prolapse of cord
c
...
Maternal diabetes
e
...
The other options are
contraindications for labor induction
...
Which interventions could a nurse apply to help stimulate contractions? (Select all that apply
...
Encouraging the patient to sit upright
b
...
Stimulating the nipples
d
...
Allowing the patient to vent frustration
ANS: A, B, C
Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor
...

DIF: Cognitive Level: Application REF: Page 177 OBJ: 3
TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28
...
)
a
...
Impaired placental exchange of oxygen and nutrients
c
...
Convulsions
e
...

DIF: Cognitive Level: Comprehension REF: Page 178 OBJ: 6
TOP: Complication of Oxytocin KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29
...
)
a
...

b
...

c
...

d
...

e
...

ANS: B, C, D
Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all
effective methods of nipple stimulation, which will increase the quality of uterine contractions
...
A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term
...
)
a
...
Placenta previa
c
...
Prolapsed cord
e
...
Gynecoid pelvis is the
most favorable shape for vaginal delivery
...
Gestational diabetes is not a contraindication
for labor induction
...
A woman is preparing for administration of a cervical ripening agent
...
)
a
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

78

b
...

c
...

d
...

e
...

ANS: A, B, C
The cervical ripening procedure should be explained to the woman and her family
...
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
...
Vital signs and fetal heart rate are also recorded
...
After an amniotomy, the umbilical cord becomes compressed
...

ANS:
amnioinfusion
A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord
...
_____________________________ is a lower-than-normal amount of amniotic fluid
...

DIF: Cognitive Level: Knowledge REF: Page 174 OBJ: 1
TOP: Amniotic Fluid KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Reduction of Risk
34
...

ANS:
laminaria
A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water
...
The nurse is assessing a newborn
...
Increased nasal mucus
b
...
Active muscle movements
d
...
One is a high-pitched cry
...
What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?
a
...
Well-contracted with its upper border three or four fingerbreadths above the umbilicus
c
...
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
...
What statement made by a new mother indicates she needs additional information about breastfeeding?
a
...

b
...

c
...

d
...

ANS: D
Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding
...
After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus
...
Notify the physician
...
Massage the fundus
...
Initiate measures that encourage voiding
...
Position the patient flat
...

DIF: Cognitive Level: Application REF: Page 202 OBJ: 9
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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80

5
...
Serosa
b
...
Alba
d
...
It is red and moderately heavy
...

DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4
TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6
...
When planning discharge teaching, the nurse
would include what information about lochia?
a
...

b
...

c
...

d
...

ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported
...
What instruction should the nurse teach the postpartum woman about perineal self-care?
a
...

b
...

c
...

d
...

ANS: B
Cleansing from front to back prevents contamination from the rectal area
...
A postpartum woman is not immune to rubella
...
The rubella virus vaccine should be administered before discharge
...
The woman should receive the rubella virus vaccine at her 6-week postpartum checkup
...
The woman should be instructed not to get pregnant until she receives the rubella vaccine
...
No intervention is indicated at this time because the woman is not at risk for rubella
...

DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2
TOP: Rubella KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9
...
I will alternate breasts when feeding the baby
...
I keep the baby on a 4-hour feeding schedule
...
I let the baby stay on the first breast only 5 minutes
...
I put only the nipple in the babys mouth when I am breastfeeding
...

DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4
OBJ: 14 TOP: Breastfeeding
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
What would the nurse include with this information?
a
...

b
...

c
...

d
...

ANS: A
To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her
prepregnancy diet
...
A woman asks about resumption of her menstrual cycle after childbirth
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4
TOP: Return of Menses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12
...
An unsensitized Rh-negative mother has an Rh-positive infant
...
An Rh-negative mother becomes sensitized
...
A sensitized infant has a rising bilirubin level
...
An unsensitized infant exhibits no outward signs
...

DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4
TOP: RhoGAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13
...
How does this action prevent heat
loss?
a
...
Radiation
c
...
Convection

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

82

ANS: C
Newborns lose heat quickly after birth as fluid evaporates from their bodies
...
What will the nurses instructions for a new mother to care for the infants umbilical cord include?
a
...
Dressing the stump with antibiotic ointment at every diaper change
c
...
Giving the newborn a daily tub bath until the cord falls off
ANS: C
Diaper placement below the umbilical stump allows for drying by air circulation
...
A new mother states her preference to formula feed her newborn
...
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
...

DIF: Cognitive Level: Application REF: Page 230 OBJ: 18
TOP: Suppression of Lactation KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16
...
She tells the nurse, I dont
think I did it right
...
Taking in
b
...
Letting go
d
...
In
doing so, she may become critical of her performance
...
A primipara tells the nurse, My afterpains get worse when I am breastfeeding
...
Ill get you some aspirin to relieve the cramping that you feel
...
Afterpains are more intense with your first baby
...
Breastfeeding releases a hormone that causes your uterus to contract
...
A change of position when youre breastfeeding might help
...

DIF: Cognitive Level: Application REF: Page 201 OBJ: 2
TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18
...
What information will the nurse include when
planning to teach the mother about formula feeding?
a
...
Heating the infant formula in a microwave
c
...
Propping a bottle for a feeding
ANS: A
The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows
...
In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section
...
Palpate from the midline to the side of the body
...
Palpate from the symphysis to the umbilicus
...
Palpate from the side of the uterus to the midline
...
Massage the abdomen in a circular motion
...

DIF: Cognitive Level: Application REF: Page 209 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
...
What statement by the
woman leads the nurse to determine that the teaching was effective?
a
...

b
...

c
...

d
...

ANS: C
Breast milk can be safely stored in glass or clear hard plastic containers
...
What should the nurse implement for security purposes when bringing the infant from the nursery to the
mother?
a
...
Confirm room number of mother
...
Ask the mother to identify herself verbally
...
Check the band number of the infant with that of the mother
...

DIF: Cognitive Level: Application REF: Page 216-217
OBJ: 8 TOP: Security Identification Procedure
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
22
...
Below 70 mg/dL
b
...
Below 50 mg/dL
d
...
If the screening sample is below 40
mg/dL, a venous sample will be drawn
...

DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 8
TOP: Hypoglycemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
23
...
Education is
provided regarding instruction on use of a sitz bath
...
Patient correctly performed return demonstration
...
Patient indicated understanding by nodding head with instruction
...
Patient verbalizes I understand
...
Family member indicates patient understands procedure
...
If
possible, when discussing sensitive information the interpreter should not be a family member, who might
interpret selectively
...
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
...
A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive
...
What is the nurses most
appropriate action?
a
...

b
...

c
...

d
...

ANS: C
If the condition of a newborn is poor, the parents may wish to have a baptism performed
...
However this is an emergency, so the nurse may perform the baptism by pouring water on the
infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit
...
The
physician is attending to the patients immediate health needs
...
A woman required a cesarean section for safe delivery of her newborn
...
What is the best suggestion by the nurse?
a
...

b
...

c
...

d
...

ANS: D
The best answer is to encourage use of the football hold to decrease pressure on the operative site
...
Some pain medications should not be taken when
breastfeeding
...
Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select
all that apply
...
Thin, transparent skin
b
...
Folded ear springs back slowly
d
...
Creases over entire sole
ANS: A, C
The only signs of preterm are the thin skin and the slowly responding ear
...
The nurse is giving a shower to a patient who had a cesarean section 2 days previously
...
)
a
...

b
...

c
...

d
...

e
...

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
...

DIF: Cognitive Level: Application REF: Page 209-211
OBJ: 5 TOP: Postpartum Shower
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28
...
)
a
...
Head lift
c
...
Kegel exercises
e
...
Leg lifts are too strenuous early in the postpartum period
...
While instructing a new mother on formula preparations, the nurse would include what types? (Select all
that apply
...
Ready-to-feed formula
b
...
Powdered formula
d
...
Canned evaporated milk
ANS: A, B, C
Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants
needs and powdered formula that is mixed as needed
...

DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 17
TOP: Formula Choices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30
...
What
interventions will the nurse suggest? (Select all that apply
...
Omit newborns 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
...
Pump breasts in place of eliminated feeding
...
One
feeding should be eliminated at a time, and the need for comfort feeding should be expected
...
The mother should not be instructed to pump in place of eliminated
feeding or the breasts will continue to produce milk
...
The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours
...

ANS:
moderate
A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge
...
The nurse explains that the three infections that are contraindications to breastfeeding are
_______________, _______________, and ________________
...

DIF: Cognitive Level: Comprehension REF: Page 222 OBJ: 13
TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
33
...

ANS:
prolactin
During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production
...

DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11
TOP: Prolactin KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
34
...

ANS:
oxytocin
The milk let-down reflex is caused by the hormone oxytocin
...
____________ refers to changes that the reproductive organs, particularly the uterus, undergo after birth to
return to their prepregnancy size and condition
...

DIF: Cognitive Level: Knowledge REF: Page 200 OBJ: 1
TOP: Puerperium KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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Chapter 10: Nursing Care of Women with Complications After Birth
MULTIPLE CHOICE
1
...
Cold, clammy skin
b
...
Hypotension
d
...

DIF: Cognitive Level: Knowledge REF: Page 238, Safety Alert
OBJ: 2 TOP: Hypovolemic Shock
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2
...
What does the nurse recognize these signs indicate?
a
...
Uterine dystocia
c
...
Uterine dysfunction
ANS: A
Atony describes a lack of normal muscle tone
...

DIF: Cognitive Level: Comprehension REF: Page 240 OBJ: 2
TOP: Atony KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3
...
Teach the patient how to massage the abdomen and then get help
...
Start IV fluids to prevent hypovolemia and then notify the registered nurse
...
Begin massaging the fundus while another person notifies the physician
...
Ask the patient to void and reassess fundal tone and location
...

DIF: Cognitive Level: Application REF: Page 240-241
OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4
...
What
should the nurses next assessment be?
a
...
Amount of lochia
c
...
Level of pain
ANS: A
Bladder distention can cause uterine atony
...

DIF: Cognitive Level: Application REF: Page 241 OBJ: 6
TOP: Bladder Distention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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5
...
What will the nurse anticipate might be ordered by the physician?
a
...
Magnesium sulfate
c
...
Bromocriptine
ANS: C
Oxytocin (Pitocin) is the most common drug ordered to control uterine atony
...
A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed
...
Stop breastfeeding until the infection clears
...
Pump the breasts to continue milk production, but do not give breast milk to the infant
...
Begin all feedings with the affected breast until the mastitis is resolved
...
Breastfeeding can continue unless there is abscess formation
...

DIF: Cognitive Level: Application REF: Page 246 OBJ: 6
TOP: Mastitis and Breastfeeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
7
...
What will the nurse plan to
teach the woman to report to help prevent postpartum complications?
a
...
Change in lochia from red to white
c
...
Fatigue and irritability
ANS: A
Increased temperature is a sign of infection
...

DIF: Cognitive Level: Application REF: Page 244 OBJ: 4
TOP: Puerperal Infections KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8
...
8 F), rust-colored lochia, and sore breasts
...
Phlebitis
b
...
Late postpartum hemorrhage
d
...
The other signs are normal in the postpartum
patient
...
Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of
late postpartum hemorrhage?
a
...

b
...

c
...

d
...

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
...
During a postpartum assessment, a woman reports her right calf is painful
...
Based on this finding, what does the nurse explain the
probable treatment will involve?
a
...
Application of ice to the affected leg
c
...
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
...
What statement by the patient leads the nurse to determine a woman with mastitis understands treatment
instructions?
a
...

b
...

c
...

d
...

ANS: B
Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast
...
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
...
Try to get more rest
...
Ill bet you will snap out of this funk real soon
...
Why dont you arrange for a babysitter so you and your husband can have a night out?
d
...
I am concerned about how you are feeling
...

DIF: Cognitive Level: Application REF: Page 247, Nursing Tip
OBJ: 6 | 7 TOP: Depression KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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13
...
Varicose veins are visible on both
legs
...
Have the woman sit in a chair for meals
...
Monitor vital signs every 4 hours and report any changes
...
Tell the woman to remain in bed with her legs elevated
...
Assist the woman with ambulation for short periods of time
...

DIF: Cognitive Level: Application REF: Page 243 OBJ: 4
TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14
...
What does the nurse recognize as the possible cause of these signs and
symptoms?
a
...
Hypovolemic shock
c
...
Cystitis
ANS: C
Fever after 24 hours following delivery is suggestive of an infection
...

DIF: Cognitive Level: Analysis REF: Page 244, Table 10-2
OBJ: 2 TOP: Puerperal Infections
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15
...

She feels guilty because sometimes she believes her infant is dead
...
Bipolar disorder
b
...
Postpartum blues
d
...

DIF: Cognitive Level: Analysis REF: Page 247 OBJ: 7
TOP: Major Depression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
16
...
What is the best nursing response
to the womans statement?
a
...
I hear this from a lot of first-time mothers
...
Have you told anyone else about your feelings?
d
...

ANS: D
The nurse may help the woman by being a sympathetic listener
...


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DIF: Cognitive Level: Application REF: Page 247 OBJ: 6 | 7
TOP: Disorders of Mood KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
17
...
What complication
should the nurse be alert for in the immediate postpartum period?
a
...
Hematoma
c
...
Retained placental fragments
ANS: B
Delivering a large infant and a prolonged labor are risk factors for hematoma formation
...
A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic
discomfort
...
Uterine massage
b
...
Dilation and curettage
d
...
Treatment may include dilation of the
cervix and curettage to remove retained placental fragments from the uterine wall
...
The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on
exertion
...
Notify the charge nurse of a possible upper respiratory infection
...
Notify the physician of a possible pulmonary embolism
...
Document expected postpartum mucous membrane congestion
...
Medicate with antipyretic remedy for elevated temperature
...
The cough with shortness of breath and
temperature elevation is a clue to this possible complication
...
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
...
Concerned and reports a probable cervical laceration
b
...
Distressed and reports a possible clotting disorder
d
...

DIF: Cognitive Level: Application REF: Page 241 OBJ: 2 | 6

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TOP: Laceration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21
...

Where does the patient report that the pain is felt?
a
...
Achilles tendon
c
...
Calf of the leg
ANS: D
A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign
...

DIF: Cognitive Level: Comprehension REF: Page 243 OBJ: 2
TOP: Homans Sign KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22
...

What action should the nurse implement?
a
...

b
...

c
...

d
...

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
...
A postpartum patient experiences anaphylactic shock
...
Pulmonary embolism
b
...
Allergy
d
...
Cardiogenic shock may be caused
by pulmonary embolism or hypertension
...

DIF: Cognitive Level: Comprehension REF: Page 237 OBJ: 3
TOP: Shock KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24
...
What will the nurse instruct
this woman is the antidote for warfarin overdose?
a
...
Vitamin B
c
...
Vitamin K
ANS: D
The antidote for warfarin overdose is vitamin K
...
A nurse is discussing risk factors for postpartum shock with a childbirth preparation class
...
)
a
...
Blood clotting disorders
c
...
Infection
e
...

DIF: Cognitive Level: Application REF: Page 237 OBJ: 3
TOP: Postpartum Shock KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
26
...
What would the nurse expect to find on further assessment? (Select all that apply
...
A firm fundus the size of a grapefruit
b
...
Retained placental fragments
d
...
A soft, boggy fundus
ANS: B, E
Large clots that form in a flaccid uterus can obstruct the flow of lochia
...

DIF: Cognitive Level: Analysis REF: Page 240 OBJ: 4
TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27
...
)
a
...
Potatoes and pasta
c
...
Rice
e
...
Starches are not
...
What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply
...
Limit fluid intake to 1 liter per day
...
Empty both breasts with each feeding
...
Take warm showers
...
Wear a supportive bra
...
Pump breasts to ensure emptying
...
All the other options are interventions to reduce

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the risk of mastitis and milk accumulation in the breast
...
A woman is diagnosed with a urinary tract infection in the postpartum period
...
)
a
...
Cranberry juice
c
...
Prunes
e
...
Apples are not considered to
increase acidity of urine
...
A postpartum patient is experiencing hypovolemic shock
...
)
a
...
Placement of an indwelling Foley catheter
c
...
Administration of anticoagulants
e
...
Anticoagulants would not be given
...
The nurse weighs a saturated perineal pad and finds it to weigh 15 grams
...

ANS:
15
The weight of 1 g in a perineal pad is equal to 1 mL of blood loss
...
The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called
_______________
...

DIF: Cognitive Level: Knowledge REF: Page 242 OBJ: 1
TOP: Subinvolution KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33
...

ANS:
hematoma
A hematoma is a collection of blood within the tissues
...
The nurse is preparing a community education program on preventive health care for women
...
Breast examination by a health professional
b
...
Breast biopsy
d
...

DIF: Cognitive Level: Comprehension REF: Page 251 OBJ: 2
TOP: Mammography KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2
...
When reviewing the procedure, when will the nurse indicate as the best time
for a woman to perform a breast self-examination?
a
...
During her menstrual period
c
...
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
...
A woman asks the nurse, How do oral contraceptives prevent pregnancy? What will the nurse explain about
the combination of estrogen and progesterone in oral contraceptives?
a
...
Prevents ovulation
c
...
Acts as a barrier by destroying sperm
ANS: B
Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation
...
What should a woman expect after insertion of an intrauterine device (IUD)?
a
...

b
...

c
...

d
...

ANS: C
A woman should feel for the string periodically, especially after her period, to confirm the presence of the
IUD
...
What information will the nurse provide when educating a woman about the correct use of a diaphragm?
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 24 hours
...
The nurse is providing sexual education to a group of high school students
...
Abstain from sex
...
Use the male condom
...
Use the female condom
...
Use the barrier method
...

DIF: Cognitive Level: Comprehension REF: Page 262 OBJ: 5
TOP: Abstinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7
...
5 C (97
...
What will her
temperature measurement most likely be if ovulation takes place on day 14?
a
...
9 C (96
...
36
...
3 F)
c
...
7 C (98
...
37
...
9 F)
ANS: C
At the time of ovulation, body temperature will increase slightly, about 0
...
4 F)
...
The nurse tells a woman who is trying to conceive to check her cervical mucus for changes
...
Cloudy and tacky
b
...
Thin and white
d
...

DIF: Cognitive Level: Knowledge REF: Page 261 OBJ: 6
TOP: Ovulation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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9
...
What information about cervical mucus at ovulation will the woman indicate to the nurse,
demonstrating that learning has taken place?
a
...

b
...

c
...

d
...

ANS: A
Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm
...
In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty
concentrating
...
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
...

DIF: Cognitive Level: Application REF: Page 254 OBJ: 3
TOP: Premenstrual Dysmorphic Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11
...
What is the primary
action of clomiphene (Clomid)?
a
...
Reduces endometriosis
c
...
Inhibits excess prolactin secretion
ANS: A
Clomiphene (Clomid) induces ovulation
...

DIF: Cognitive Level: Knowledge REF: Page 272 OBJ: 7
TOP: Clomid KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
12
...
What suggestion can the nurse make to this patient?
a
...

b
...

c
...

d
...

ANS: C
Foods rich in calcium include milk, dairy products, and green, leafy vegetables
...
A 48-year-old woman tells the nurse, I missed my period last month
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 274 OBJ: 8
TOP: Menopause KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14
...
What would the nurse include regarding
lowered estrogen level?
a
...

b
...

c
...

d
...

ANS: C
Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver
for excretion
...

DIF: Cognitive Level: Knowledge REF: Page 274 OBJ: 8
TOP: Menopause KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15
...
Fatigue
b
...
Weight loss
d
...

DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 8
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16
...
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
...
Layering allows the woman to take off or put on
clothes when symptoms occur
...
Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock
syndrome (TSS)?
a
...

b
...

c
...

d
...

ANS: B
Tampons should be changed every 4 hours because a blood-soaked tampon is an excellent environment for
bacteria
...
What statement by a man considering a vasectomy indicates a need for further information?
a
...

b
...

c
...

d
...

ANS: D
A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia
...
At her 6-week postpartum checkup, a woman states, I am wondering about birth control
...
Can I use the pill again? What is the nurses best response?
a
...

b
...

c
...

d
...

ANS: B
Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established
...

DIF: Cognitive Level: Application REF: Page 263 OBJ: 5
TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20
...
An ovarian cyst is suspected
...
Laparotomy
b
...
Transvaginal ultrasound
d
...

DIF: Cognitive Level: Analysis REF: Page 278 OBJ: 10
TOP: Ovarian Cysts KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
21
...


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Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese
appearance
...
Candidiasis
b
...
Bacterial vaginosis
d
...

DIF: Cognitive Level: Analysis REF: Page 257, 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
22
...
Which of the following decrease
effectiveness of oral contraceptives?
a
...
Iron preparations for treatment of anemia
c
...
Anticonvulsants for treatment of epilepsy
ANS: D
Anticonvulsants decrease the effectiveness of oral contraceptives
...
The nurse is instructing a man considering a vasectomy
...
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 sperm
count after that period of time should be performed to confirm the absence of sperm
...
Erections and sexual pleasure are not
affected by a vasectomy
...
A woman diagnosed with endometriosis reports painful intercourse
...
Dyspnea
b
...
Dyspareunia
d
...
Dyspnea is shortness of breath
...
Dysrhythmia is irregular heart rhythm
...
The nurse is educating a woman diagnosed with Premenstrual Dysphoric Disorder (PMDD)
...
High protein, low fat
b
...
Low calorie, low fat
d
...

DIF: Cognitive Level: Application REF: Page 254 OBJ: 3
TOP: PMDD KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
26
...
)
a
...
Weight gain
c
...
Eye or visual problems
e
...
Weight gain is an expected side effect of oral contraceptives
...
What are anonymous sperm donors screened for? (Select all that apply
...
Particular physical features
b
...
Infections
d
...
Nationality
ANS: B, C, D
Sperm donors are screened for genetic defects, infections, and high-risk behaviors
...

DIF: Cognitive Level: Comprehension REF: Page 272 OBJ: 6
TOP: Sperm Donors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28
...
)
a
...
Estrogen-dependent breast cancer
c
...
Thromboembolic disease
e
...

DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 9
TOP: HRT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
29
...
The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (Select
all that apply
...
Antihypertensive drugs
b
...
Alcohol
d
...
NSAIDs
ANS: A, B, C, D
Foods and drugs that increase the symptoms of urge incontinence are antidepressants, angiotensin converting
enzyme (ACE) inhibitors, caffeine, alcohol, and diuretics
...

DIF: Cognitive Level: Application REF: Page 278 OBJ: 10
TOP: Urge Incontinence KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
30
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, B, C, E
Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation
will reduce the pelvic discomfort of pelvic floor dysfunction
...
A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause
...
Drink 8 oz
...

b
...

c
...

d
...

ANS: A
Alendronate (Fosamax) may be prescribed
...
Weight-bearing exercises such as walking, hiking, stair
climbing, and dancing are advisable
...

DIF: Cognitive Level: Comprehension REF: Page 275 OBJ: 2 | 8
TOP: Osteoporosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
32
...
What information can
the nurse provide? (Select all that apply
...
It involves laser destruction of fibroids
...
It has fewer physiological effects than drug therapy
...
It is nonsurgical
...
It is associated with more psychological effects than surgery
...
It has a faster recovery time than surgery
...
Myolysis is the laser or electrosurgical destruction of fibroids, and it also preserves fertility
...
The nurse outlines the process of ova being mixed with sperm and then the resulting embryos being
returned to the mothers uterus
...

ANS:
in vitro fertilization
The in vitro fertilization technique mixes ova with sperm and deposits several of the resulting embryos in the
mothers uterus
...
When intraabdominal pressure increases from laughing or sneezing in a woman with a cystocele,
__________ ___________ results
...

DIF: Cognitive Level: Knowledge REF: Page 277 OBJ: 10
TOP: Cystocele KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35
...

ANS:
Endometriosis
Endometriosis is the presence of tissue that resembles endometrium outside the uterus
...
While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture
line
...
Molding
b
...
Cephalohematoma
d
...
It does not
cross the suture line
...
What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old
infant?
a
...
Dont worry about it
...
Did you deliver vaginally or by cesarean section?
c
...
It will go away soon
...
A traumatic delivery can cause molding
...
This refers to the shaping of the fetal head to conform
to the size and shape of the birth canal
...
What symptom assessed in the newborn shortly after delivery should be reported?
a
...
Irregular heart rate
c
...
Sternal or chest retractions
ANS: D
Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately
...
When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out,
and then both came back toward the midline
...
The Moro reflex
b
...
An abnormality of the musculoskeletal system
d
...
It is elicited when the infants crib is jarred
...


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DIF: Cognitive Level: Analysis REF: Page 282, Figure 12-3 | Page 284, Table 12-1
OBJ: 2 TOP: Newborn Reflexes
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5
...
Which neonatal
reflex would the nurse teach the mother to elicit to facilitate breastfeeding?
a
...
Rooting
c
...
Tonic neck
ANS: B
The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in
anticipation of food
...
What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?
a
...
Triangular shaped
c
...
Open and diamond shaped
ANS: D
The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones
...

DIF: Cognitive Level: Comprehension REF: Page 283 | Page 285 Skill 12-1
OBJ: 3 TOP: Newborn AssessmentHead
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7
...
Ill use a mild soap to clean all of the body parts
...
I am going to add bath oil to the water to keep the babys skin soft
...
I should shampoo the head after washing the rest of the body
...
Ill wash from the feet upward and change the washcloth for the face
...

DIF: Cognitive Level: Comprehension REF: Page 295 | Page 298 Skill 12-5
OBJ: 8 TOP: Home CareBathing the Infant
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8
...
Which finding is abnormal?
a
...
6 C (98 F)
b
...
Respirations of 35 breaths/min
d
...
A pulse rate outside of this range should
be reported
...
The nurse is caring for a newborn who is being breastfed
...
Yellow
b
...
Greenish brown
d
...

DIF: Cognitive Level: Application REF: Page 299, Figure 12-15
OBJ: 8 TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
Ive noticed she strains
when she has a bowel movement
...
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 arent fully developed
...
It results from underdeveloped abdominal musculature
...

DIF: Cognitive Level: Application REF: Page 300 OBJ: 8
TOP: Newborn AssessmentGastrointestinal System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11
...
What would the nurse expect the newborn to weigh in
grams 3 days later?
a
...
3100
c
...
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
...
The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be
bloody mucus
...
Premature stimulation of the ovarian hormones by the pituitary system
b
...
The increased amount of circulating blood from the mother throughout pregnancy
d
...

DIF: Cognitive Level: Comprehension REF: Page 293 OBJ: 8
TOP: Newborn AssessmentGenitourinary
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13
...
What is the most
appropriate nursing response to this mother?
a
...

b
...

c
...

d
...

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
...
Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?
a
...
Infant has an axillary temperature of 97 F
c
...
Infants diaper is not wet after 8 hours
ANS: D
Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to
prevent dehydration
...
On what knowledge would the nurse base a response to a mother who questions, Do you think my baby
recognizes my voice?
a
...

b
...

c
...

d
...

ANS: D
The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days
of life
...
The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had
lost weight
...
Do nothing because this is a normal occurrence
...
Report the discrepancy to the pediatrician immediately
...
Decrease the interval between the infants feedings
...
Try feeding the infant a different type of formula
...
No
change in the plan of care is needed
...
Parents express concern about the milia on the face and nose of their infant
...
Contact a pediatric dermatologist for topical medication
...
Squeeze out the white material after cleansing the face
...
Wash the infants face with a mild astringent several times a day
...
Leave the milia alone; it will disappear spontaneously
...

ANS: D
Milia require no treatment
...

DIF: Cognitive Level: Application REF: Page 294 | Page 297 Table 12-3
OBJ: 5 TOP: Newborn AssessmentSkin
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18
...
What is the
nurses first action?
a
...

b
...

c
...

d
...

ANS: C
The bulb is depressed, and then the tip is inserted into the mouth and then the nose
...

DIF: Cognitive Level: Application REF: Page 288 | Page 289 Skill 12-2
OBJ: 3 TOP: Newborn AssessmentRespiratory
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19
...

Which finding needs to be reported promptly to the childs pediatrician?
a
...

b
...

c
...

d
...

ANS: D
Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week
...

DIF: Cognitive Level: Analysis REF: Page 294 OBJ: 6
TOP: Newborn AssessmentSkin (Jaundice)
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
20
...
Keep the newborn dressed warmly
...
Adjust room temperature between 23
...
6 C (80 F)
...
Wash hands before touching each infant
...
Wear a disposable gown when giving infant care
...
The nurse washes his or her hands
between handling different babies
...
Which assessment of the newborn should be reported?
a
...
Hands and feet are warm with a blue color
c
...
6 C (97
...
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
...

DIF: Cognitive Level: Analysis REF: Page 285, 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
...
What does the nurse
explain this transitory skin discoloration is called?
a
...
Milia
c
...
Mongolian spots
ANS: D
Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots
...
The pediatric clinic nurse receives lab results on several newborn patients
...
White blood cell count of 18,000
b
...
5
c
...
Bilirubin of 15
ANS: D
A bilirubin of 15 is elevated and requires further immediate investigation
...
The nurse is assessing Apgar score on a newborn
...
)
a
...
Color

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c
...
Respiration
e
...

Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color
...

DIF: Cognitive Level: Application REF: Page 289 OBJ: 3
TOP: Apgar Score KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
25
...
)
a
...
Rocking
c
...
Distraction
e
...
Distraction is not a dependable method of pain reduction with infants
...
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 newborns physiology? (Select all that apply
...
Very little subcutaneous fat
b
...
Ineffective sweat glands
d
...
Low red blood cell counts
ANS: A, C
Newborns have very little subcutaneous fat, which offers little insulation against cold
...

DIF: Cognitive Level: Comprehension REF: Page 290 OBJ: 4
TOP: Environmental Thermal Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27
...
)
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
...
The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply
...
Blinking
b
...
Gagging
d
...
Grasping
ANS: A, B, C, D, E
All listed reflexes are present in the full-term newborn
...
The nurse takes into consideration that newborns are especially prone to dehydration because of which
aspects of their physiology? (Select all that apply
...
Small glomeruli
b
...
Inactive gastrointestinal (GI) tract
d
...
Immature renal tubules that do not concentrate urine
ANS: A, B, E
The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are
unable to effectively concentrate urine
...
The infants sweat glands do not work effectively
and allow very little fluid loss through sweat
...
The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to _____________
assessment
...

DIF: Cognitive Level: Comprehension REF: Page 287-288
OBJ: 3 TOP: Pain Assessment Guides
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31
...

ANS:
IgA
IgA is an immune globulin that is found in breast milk
...
The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow
color, this is normal __________ stool
...

DIF: Cognitive Level: Comprehension REF: Page 299, Figure 12-15
OBJ: 8 TOP: IgA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
33
...

ANS:
dancing reflex
Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the
dancing reflex
...
Place the newborn phases of the sleep-wake states in proper order from first to last
...
)
a
...
First reactive phase
c
...
Second reactive phase
ANS:
B, C, D, A
At birth the newborn passes through the phases of sleep-wake states as part of the adjustment to life outside of
the uterus: first reactive phase, sleep phase, second reactive phase, stability phase
...
Put the steps of nasal bulb suctioning for the newborn in the correct order from first to last
...
)
a
...

b
...

c
...

d
...

e
...

ANS:
D, C, B, E, A
First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose
...
The bulb syringe is cleaned
and stored at the end of the procedure
...
The nurse is assessing a preterm infant
...
Actual time the fetus remained in the uterus
b
...
Infants weight as compared to the gestational age
d
...

DIF: Cognitive Level: Knowledge REF: Page 309 OBJ: 1
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
The nurse knows that this infant is at
risk for what?
a
...
Renal failure
c
...
Heart failure
ANS: C
The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage
...
Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first
few days of life?
a
...
Inability to digest food properly
c
...
Need for a larger quantity of formula at each feeding
ANS: A
When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to
promote nutrition
...
What deficiency causes a preterm infant respiratory distress syndrome?
a
...
Estrogen
c
...
Surfactant
ANS: D
The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm
infant
...
How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?
a
...

b
...

c
...

d
...

ANS: C
When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is
started
...

DIF: Cognitive Level: Application REF: Page 317 OBJ: 6
TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6
...
Prostaglandins
b
...
Magnesium sulfate
d
...

DIF: Cognitive Level: Comprehension REF: Page 312 OBJ: 4
TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7
...
What is the most appropriate
nursing action in this situation?
a
...

b
...

c
...

d
...

ANS: B
Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe
...
What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium
gluconate?
a
...
Bradycardia
c
...
Tetany
ANS: B
The infant receiving intravenous calcium gluconate should be monitored for bradycardia
...
What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator?
a
...

b
...

c
...

d
...

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
...
What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen
therapy?
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)
...
When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory
grunting
...
Respiratory distress syndrome
b
...
Apneic episode
d
...
The signs manifested by
the infant are indicative of respiratory distress
...
What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a
bloody stool?
a
...

b
...

c
...

d
...

ANS: A
Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis
...

DIF: Cognitive Level: Application REF: Page 317 OBJ: 4
TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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13
...
What
will the nurse teaching about stimulating the infant tell the parents?
a
...
That stimulating the infant during feedings increases intake
c
...
Not to disturb the infant between feedings
ANS: C
During gavage feedings, stroking the infant gently can provide stimulation
...
The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry
...
Respiratory distress syndrome
b
...
Necrotizing enterocolitis
d
...

DIF: Cognitive Level: Analysis REF: Page 314 OBJ: 4
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15
...
What is the most appropriate nursing response?
a
...

b
...

c
...

d
...

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
...
The nurse caring for a preterm infant will record the intake and output
...
1 to 3 mL/kg/hr
b
...
7 to 9 mL/kg/hr
d
...

DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 4
TOP: Immature Kidneys KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
17
...
What physical characteristic might the

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120

nurse expect this infant to exhibit?
a
...
Large genitals for its size
c
...
Loose, transparent skin
ANS: D
The growth and development of the fetus are abruptly halted by a preterm birth
...

DIF: Cognitive Level: Comprehension REF: Page 309 OBJ: 2
TOP: Preterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18
...
The nurse knows that the infant should be evaluated in what month of achievement
to adjust for the preterm birth?
a
...
2
c
...
4
ANS: B
The growth and development of a preterm infant are based on the current age minus the number of weeks
before term that the infant was born
...
The mother of a postterm infant asks the nurse why the infant is being watched so closely
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9
TOP: Postterm Infant KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20
...
Tremors and weak cry
b
...
Warm skin with low core temperature
d
...

DIF: Cognitive Level: Comprehension REF: Page 314, Nursing Tip
OBJ: 5 TOP: Preterm Infant
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk

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21
...
What would the physical assessment reveal?
a
...
Minimal hair on the head
c
...
Abundant lanugo on the body
ANS: A
Loss of vernix caseosa leaves the skin dry, causing peeling
...
What term describes the age of a neonate that is based on the actual time in utero?
a
...
Gestational age
c
...
Chronological age
ANS: B
The gestational age is the age based on the actual time in the uterus
...
How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and
the incubator?
a
...
Every 2 hours
c
...
Every 8 hours
ANS: B DIF: Cognitive Level: Comprehension REF: Page 314
OBJ: 5 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
24
...
Inadequate vernix caseosa
b
...
Polycythemia
d
...

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9
TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25
...
What will the nurse consider this newborn?
a
...
Small for gestational age
c
...
Late preterm
ANS: C

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122

Term infants over 4000 g (8
...
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
...

DIF: Cognitive Level: Analysis REF: Page 308-309
OBJ: 1 TOP: Gestational Age
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26
...
When will the nurse anticipate seeing improvement of lung function?
a
...
Within 3 days
c
...
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
...
The nurse knows that a postterm infant may experience which potential problems? (Select all that apply
...
Seizures
b
...
Paralysis
d
...
Polycythemia
ANS: A, B, E
The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia
...
The nurse is caring for a woman who gave birth to a preterm infant
...
)
a
...
Gestational diabetes
c
...
Hyperemesis gravidarum
e
...
Prematurity
may be caused by multiple births, illness of the mother (e
...
, 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
...
Hyperemesis gravidarum and chloasma are not risk factors for preterm birth
...
The nurse assesses a preterm infant in the NICU
...
)
a
...
Transparent skin
c
...
Vomiting
e
...
Transparent
skin and superficial scalp veins are expected findings
...
The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____ weeks
...

DIF: Cognitive Level: Knowledge REF: Page 312 OBJ: 2
TOP: Surfactant KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31
...

ANS:
feeding
Preterm babies should not be stimulated during feeding so they can focus on sucking and swallowing
...
Assessment of altered skin integrity in the preterm infant is made difficult because of the immature
immune system that cannot produce a(n) __________ reaction
...
Without
such symptoms, skin integrity is more difficult to assess in the preterm infant
...
The nurse encourages the anxious mother of a preterm infant to consider the warming technique of holding

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124

the infant between her breasts with skin-to-skin contact under a blanket
...

ANS:
kangaroo
The kangaroo care method is when the mother places the infant between her breasts for skin-to-skin contact,
and then both mother and infant are wrapped in a blanket as a warming technique
...

DIF: Cognitive Level: Knowledge REF: Page 317 OBJ: 5 | 7
TOP: Kangaroo Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34
...

ANS:
prothrombin
Preterm infants have deficient levels of prothrombin, which increases the tendency to bleed spontaneously
...
The nurse explains that the _____________ ___________ is a tool used to determine the gestational age of
a neonate based on appearance and neuromuscular criteria
...

DIF: Cognitive Level: Knowledge REF: Page 310, Figure 13-2
OBJ: 1 TOP: Ballard Scoring System
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36
...

ANS:
oxygen
Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy
...
What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of
cerebrospinal fluid?
a
...
Meningocele
c
...
Hydrocephalus
ANS: D
Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain
...
The nurse is caring for an infant with hydrocephalus
...
Align the limbs
...
Support the head
...
Keep the head lower than the hip
...
Check intake and output
...

DIF: Cognitive Level: Application REF: Page 327 OBJ: 4
TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
3
...
How should the nurse position this infant?
a
...
Supine, with the head flat
c
...
In a semi-Fowlers position
ANS: D
If the fontanelles are bulging, the child will be positioned in a semi-Fowlers position to promote drainage from
the ventricles through the shunt
...
What nursing action will the nurse implement after feeding an infant with hydrocephalus?
a
...

b
...

c
...

d
...

ANS: C
Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-

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126

lying position in a quiet atmosphere to reduce the incidence of vomiting
...
A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele
...
Keep the sac dry
...
Diaper snugly
...
Position prone in an incubator
...
Move from side to side every hour
...
The
infants hips are kept lower than the lesion, and the infant is usually not in diapers
...
The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and
observes an increasing abdominal girth
...
Elevate the childs head
...
Check bowel sounds
...
Record retention of feeding
...
Notify the charge nurse of possible malabsorption
...

DIF: Cognitive Level: Application REF: Page 327-328
OBJ: 6 TOP: VP Shunt KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7
...
What will the nurse instruct the
parents to report immediately?
a
...
Ear infections
c
...
Drooling
ANS: B
Children with cleft palate are at risk of ear infections and dental disorders
...

DIF: Cognitive Level: Application REF: Page 332 OBJ: 7
TOP: Complication of Cleft Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8
...
Feeding the infant with a spoon to avoid sucking
b
...
Applying elbow restraints to protect the surgical area
d
...


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127

DIF: Cognitive Level: Application REF: Page 332 OBJ: 7
TOP: Cleft Lip and Palate KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
9
...
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
...

DIF: Cognitive Level: Application REF: Page 332 OBJ: 7
TOP: Cleft Lip and Palate KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
10
...
What
nursing action is the most appropriate?
a
...

b
...

c
...

d
...

ANS: A
The primary concern with feeding is to protect the operative site
...
The spoon must not touch the roof of
the mouth
...
When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?
a
...
One leg is shorter than the other
c
...
Two skinfolds on the back of each thigh
ANS: B
When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on
the unaffected side
...
A 3-month-old infant is diagnosed with developmental hip dysplasia
...
A Pavlik harness
b
...
Traction
d
...


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128

DIF: Cognitive Level: Comprehension REF: Page 334, Figure 14-10
OBJ: 8 TOP: Developmental Hip Dysplasia
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
13
...
The nurse explains that what is the
optimal time for testing for phenylketonuria?
a
...
After 2 to 3 days
c
...
At 2 months of age
ANS: B
Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth
...

DIF: Cognitive Level: Comprehension REF: Page 337 OBJ: 9
TOP: PKU KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14
...
What formula and/or diet
should the nurse suggest?
a
...
A formula that is low in the amino acid leucine
c
...
Substitute Lofenalac for some protein foods
ANS: D
A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted
for natural protein foods
...
Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric clinic
...
Preventing hyperthermia
b
...
Prevention of diarrhea
d
...

DIF: Cognitive Level: Application REF: Page 339-340
OBJ: 10 TOP: Down Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
16
...
Prop the child upright with pillows for meals
...
Use the bar between the legs to turn the child
...
Put the child on her abdomen to sleep
...
Change the childs position frequently
...

DIF: Cognitive Level: Application REF: Page 335 OBJ: 8
TOP: Developmental Hip Dysplasia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
17
...
What scenario indicates the need to
administer RhoGAM to this patient?
a
...

b
...

c
...

d
...

ANS: B
The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rhpositive child and is now pregnant with another
...
Parents ask the nursery staff what the light does for their jaundiced infant
...
The light increases the infants metabolism
...
The light stimulates liver function
...
The light dilates blood vessels
...
The light breaks down bilirubin
...
The light breaks down excess bilirubin so that it can be excreted
...
Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired
...
Immediately after birth
b
...
After 12 months of age
d
...

DIF: Cognitive Level: Comprehension REF: Page 331 OBJ: 7
TOP: Cleft Lip KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20
...
What is the most appropriate nursing action for the infant having
phototherapy?
a
...

b
...

c
...

d
...

ANS: C

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The infants eyes are protected with patches to prevent damage from the high-intensity lights
...
The nurse is caring for a macrosomic newborn whose mother has diabetes
...
Hypoglycemia
b
...
Intracranial hemorrhage
d
...

DIF: Cognitive Level: Application REF: Page 347 OBJ: 15
TOP: Infant of a Diabetic Mother KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
22
...
Asymmetrical gluteal folds
b
...
Foot turned inward
d
...
There is
also limited abduction of the affected side, and when the legs are flexed the affected leg seems to be shorter
...
The nurse is providing care to a child with Down syndrome
...
Reproductive system
b
...
Cardiovascular system
d
...

DIF: Cognitive Level: Knowledge REF: Page 339 OBJ: 10
TOP: Down Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
24
...
What is the
most appropriate response?
a
...

b
...

c
...

d
...

ANS: B

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Inborn errors of metabolism include a number of inherited diseases that affect body chemistry
...
The deficient substance is usually an
enzyme
...
Examples of inborn errors of metabolism include
cystic fibrosis and phenylketonuria (PKU)
...
Sickle cell disease, thalassemia, and
hemophilia fall into this category
...
Most involve some
type of mental retardation, and others are incompatible with life
...
Malformations at birth
include several types of structural defects
...
What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply
...
Close-set eyes
b
...
Wide-spaced front teeth
d
...
Curved, small fingers
ANS: A, B, D, E
Children with Down syndrome have close-set upturned eyes, simian creases in palms of hands, protruding
tongues, and curved, small fingers
...

DIF: Cognitive Level: Knowledge REF: Page 339, Figure 14-12
OBJ: 10 TOP: Features of Down Syndrome
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26
...
)
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
...

DIF: Cognitive Level: Comprehension REF: Page 346 OBJ: 2
TOP: Topic: Intracranial Hemorrhage KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
27
...
)
a
...

b
...

c
...

d
...

e
...


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ANS: A, B, C, E
The casted leg should be kept elevated
...

DIF: Cognitive Level: Comprehension REF: Page 332-333
OBJ: 2 TOP: Repair of Clubfoot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
28
...
What would be the manifestations of this syndrome? (Select all that apply
...
Body tremors
b
...
Hyperirritability
d
...
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
...
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all
that apply
...
High-pitched cry
b
...
Bulging fontanelles
d
...
Hiccups
ANS: A, B, C
Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles
...
The nurse is obtaining intake information on a new patient being seen for preconception care and notes a
family history of neural tube defects
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, C
The use of drugs during early pregnancy and poor nutrition may contribute to the development of a neural tube
defect
...
4 mg of folic acid and continue the intake of folic acid until the twelfth week
of pregnancy, when basic neural tube development is completed
...
Daily
exercise and bed rest do not decrease the risk of neural tube anomalies
...
The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes
immediately after birth
...
)
a
...
Weight of 9 pounds or more
c
...
Hypocalcemia
e
...
When the mother is hyperglycemic,
large amounts of glucose are transferred to the fetus
...
Hyperinsulinism, along with excess production of protein and fatty
acids, often results in a newborn infant who weighs more than 4082 g (9 lb)
...

DIF: Cognitive Level: Comprehension REF: Page 346-347
OBJ: 15 TOP: Macrosomic Newborn
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
32
...
What will the nurse include when
providing information to these parents?
a
...

b
...

c
...

d
...

e
...

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
...
It is
not necessary to cover the infants eyes when under the light
...
When the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting
hydrocephalus is diagnosed as ____________________ hydrocephalus
...

DIF: Cognitive Level: Comprehension REF: Page 325 OBJ: 4
TOP: Communicating Hydrocephalus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
34
...
This type of spina bifida is known as a(n) ____________________
...

DIF: Cognitive Level: Comprehension REF: Page 328 OBJ: 6
TOP: Meningomyelocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
35
...

ANS:
pump
A small pump is part of the VP shunt
...
The shunt can be pumped
according to the physicians instructions to maintain flow from the ventricles to the peritoneum
...
The initial treatment for cleft lip is a surgical repair known as ______________
...

DIF: Cognitive Level: Knowledge REF: Page 331 OBJ: 1
TOP: Cleft Lip Repair KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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Chapter 15: An Overview of Growth, Development, and Nutrition
MULTIPLE CHOICE
1
...
Specific to general
b
...
Cephalocaudal
d
...

DIF: Cognitive Level: Comprehension REF: Page 353, Figure 15-1
OBJ: 1 TOP: Cephalocaudal Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
Environment
b
...
Personality
d
...

DIF: Cognitive Level: Knowledge REF: Page 360 OBJ: 1
TOP: Personality Development KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3
...
What can the nurse project the weight to be at 6 months?
a
...
15 pounds
c
...
22 pounds
ANS: B
An infant usually doubles his or her birth weight by 5 to 6 months
...
What would the nurse further investigate when assessing patterns of growth in a child?
a
...

b
...

c
...

d
...

ANS: A
The child showing a difference of two or more percentile levels from an established growth pattern should
undergo further evaluation
...
A mother reports that she and her husband have had one child together, but both have children from
previous marriages living in their home
...
Nuclear
b
...
Alternate
d
...

DIF: Cognitive Level: Comprehension REF: Page 359, Table 15-1
OBJ: 6 | 7 TOP: The Family KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
6
...
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
...
4
c
...
8
ANS: C
The 1-year-old infant usually has about 6 teeth, 4 above and 2 below
...
At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first dental visit
...
If the teeth are brushed regularly, the child should see a dentist by 3 years of age
...
The first dental visit should be arranged after the first tooth erupts
...
The child should have a dental examination when all deciduous teeth have erupted
...
A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry
...

DIF: Cognitive Level: Application REF: Page 380 OBJ: 10
TOP: Dentition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8
...
The nurse will explain
that permanent teeth begin erupting at what age?
a
...
6 years old
c
...
10 years old
ANS: B
Permanent teeth do not erupt through the gums until the sixth year
...
A mother asks the nurse how much food should be offered to her 2-year-old
...
2
b
...
4
d
...

DIF: Cognitive Level: Comprehension REF: Page 380 OBJ: 9
TOP: Rule of Thumb for Serving Sizes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10
...
How would this childs nutritional status be described?
a
...
Undernourished
c
...
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
...
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
...
Dried beans mixed with rice
b
...
Spaghetti and meatballs
d
...

DIF: Cognitive Level: Comprehension REF: Page 372, Table 15-6
OBJ: 7 TOP: Feeding the Ill Child
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12
...
What does self-feeding
help to develop in the toddler?
a
...
A sense of independence
c
...
Healthy teeth
ANS: B
By the end of the second year, toddlers can feed themselves
...

DIF: Cognitive Level: Comprehension REF: Page 368, Table 15-3
OBJ: 2 TOP: Feeding the Healthy Child
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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13
...
Completing a 50-piece jigsaw puzzle
b
...
Playing a game of I Spy with the nurse
d
...
The
completion of a jigsaw puzzle is industrious play
...
What does the nurse recognize as an example of Piagets concrete operational thinking?
a
...

b
...

c
...

d
...

ANS: D
The 7-year-olds remark reflecting the cause and effect of germs and illness is an example of operational
thinking
...

DIF: Cognitive Level: Analysis REF: Page 369, Table 15-4
OBJ: 8 TOP: Cognitive Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15
...

What statement by the mother leads the nurse to determine that learning has taken place?
a
...

b
...

c
...

d
...

ANS: A
Solid foods are usually introduced at about 6 months of age, starting with rice cereal, which is the least
allergenic
...
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
...

b
...

c
...

d
...

ANS: D
The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation
...
The mother of a 7-month-old states, The baby is eating food now
...
You should give the baby low-fat milk
...
Try the milk
...

c
...

d
...

ANS: C
Whole milk should not be introduced before 1 year of age
...

DIF: Cognitive Level: Application REF: Page 377, Nursing Tip
OBJ: 9 TOP: Nutrition and Health
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18
...
What type of play does the nurse recognize these children are participating in?
a
...
Cooperative
c
...
Fantasy
ANS: B
In cooperative play, children play with each other, each taking a specific role
...
When the nurse asks a 10-year-old Native American if he is ready to go to therapy, he does not answer
immediately
...
Indecision
b
...
Shyness with strangers
d
...
They need to sit and consider matters before replying to questions
...
A mother tells the nurse, My 11-month-old son is not as active as my other children were at this age
...
Which factor is influencing this childs
language development?
a
...
Sex
c
...
Ordinal position
ANS: D
Motor development of the youngest child may be prolonged if the child is babied by others in the family
...
A mother tells her 4-year-old child that balls should be played with outside and not inside the house
...
The child does not want to be punished
...
The child wants to please her mother
...
The child respects authority figures
...
The child believes that following the rules is right
...

DIF: Cognitive Level: Comprehension REF: Page 368, Table 15-3
OBJ: 8 TOP: Moral Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22
...
Talking directly to the mother
b
...
Touching the childs head
d
...

DIF: Cognitive Level: Application REF: Page 363, Table 15-2
OBJ: 7 TOP: Ethnic ConsiderationsVietnamese
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
23
...
2 meters) and weighs 100 pounds (45
...
28
...
32
...
34
...
37
...
4 (weight in kg) divided by 1
...
2 squared) = 32
...
A BMI of over 30 is classified as obese
...
What toy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old child?
a
...
Book of nursery rhymes
c
...
Model car construction kit
ANS: C
At this age children are into creative play
...

DIF: Cognitive Level: Application REF: Page 384, Table 15-10
OBJ: 11 TOP: Play Activities
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25
...
What nursing
intervention is the nurse most likely implementing by using this form of therapeutic play?
a
...
Encouraging deep breathing
c
...
Maintaining body temperature
ANS: B
Play can also be therapeutic and aid in the recovery process
...

DIF: Cognitive Level: Application REF: Page 384 OBJ: 14
TOP: Therapeutic Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
26
...
What is the
most accurate response by the nurse?
a
...
5 to 7 hours a night with one daytime nap
c
...
4 to 6 hours a night with two daytime naps
ANS: C
Sleep patterns vary with age
...
The 2-year-old may sleep 10 hours during the night and have only one short daytime nap
...
These patterns may be altered
by cultural practices
...
How do children differ from adults? (Select all that apply
...
Higher metabolic rate
b
...
Less mature organ systems
d
...
Continuously changing growth and development pattern
ANS: A, B, C, E
Children are in a continuous growth and development pattern
...
All of their organ systems are not mature
...
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
...
Sweets and milk should not be offered
until after solid food
...
Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select all that
apply
...
Bubble gum
b
...
Raw vegetables
d
...
Dried fruits
ANS: C, D
Cheese and raw vegetables are acceptable healthy snacks
...

DIF: Cognitive Level: Comprehension REF: Page 376, Table 15-8, 379
OBJ: 9 TOP: Healthy Snacks
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30
...

How does this tool help with selection of portion sizes? (Select all that apply
...
Cartoon characters eating healthy foods
b
...
Portion measurement in tablespoons for common food
d
...
Familiar objects such as a deck of cards to measure servings
ANS: B, E
The Portion Plate for Kids is a placemat that uses common objects such as a deck of playing cards or a baseball
to measure serving portions
...
An educational program is being presented to pediatric nurses on the relationship of play to childhood
development
...
)
a
...

b
...

c
...

d
...

e
...

ANS: C, D, E
Art is an appropriate play activity at almost any age and provides an avenue for experimentation as well as for
creative expression and a feeling of accomplishment in the child
...
Any plan

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143

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
...

DIF: Cognitive Level: Comprehension REF: Page 383-384
OBJ: 12 | 15 TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...
When
asked about it, the boy states, I play games on my computer for 1 hour a day
...
)
a
...
Gross motor development
c
...
Learning opportunities
e
...

DIF: Cognitive Level: Comprehension REF: Page 384 OBJ: 13
TOP: Computer Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
33
...

ANS:
folk healer, curandero
Hispanics have faith in the effect of the curandero and are soothed by the ceremonies
...
The nurse assesses an unmet need in a hospitalized child who clings to his mother as she is about to leave
...

ANS:
love, belonging
The hospitalized child displaying these symptoms may feel a loss of love and a lack of belonging to the family
unit
...
The nurse cautions that children who are put to sleep with a bottle are at risk for a dental problem called
___________ _____________
...

DIF: Cognitive Level: Knowledge REF: Page 382, Figure 15-14
OBJ: 9 TOP: Nursing Caries
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
36
...

ANS:
infant
A child between the ages of 4 weeks and 1 year is termed an infant
...
__________ refers to standing measurement, whereas _______ refers to measurement while the infant is in
a recumbent position
...

DIF: Cognitive Level: Knowledge REF: Page 353 OBJ: 1
TOP: Physical Development KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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Chapter 16: The Infant
MULTIPLE CHOICE
1
...
What is the most helpful measure the
nurse can suggest to the mother?
a
...

b
...

c
...

d
...

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
...
When does the posterior fontanelle close?
a
...
3 to 6 months
c
...
9 to 12 months
ANS: A
The posterior fontanelle closes between 2 and 3 months of age
...
At what age does an infants birth weight triple?
a
...
1 year
c
...
2 years
ANS: B
The infant usually triples his or her birth weight by about 12 months of age
...
What is the earliest age at which an infant is able to sit steadily alone?
a
...
5 months
c
...
15 months
ANS: C
The infant can sit alone without support at about 8 months of age
...
What is the earliest age at which the infant should be able to walk independently?
a
...
12 to 15 months
c
...
18 to 21 months
ANS: B
For the majority of children, the milestone of walking alone is achieved between 12 and 15 months
...
The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a
cup? What is the nurses most accurate response?
a
...
9 months
c
...
2 years
ANS: A
The infant can usually drink from a cup when it is offered at about 5 months
...
What would the nurse expect a 4-month-old to be able to accomplish?
a
...

b
...

c
...

d
...

ANS: C
Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the
infant learns to do first
...

DIF: Cognitive Level: Comprehension REF: Page 391, Box 16-1
OBJ: 3 TOP: Development and Care
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8
...
Weight gain of 4 to 7 ounces per week
b
...
Head lag present
d
...
If head lag is present at 6 months, the child
should undergo further evaluation
...
A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination
...
What will the nurse weighing the infant today would expect her weight to be?
a
...
At least 16 pounds
c
...
At least 24 pounds
ANS: B
Birth weight is usually doubled by 6 months of age
...
What will the nurse advise a parent to do when introducing solid foods?
a
...

b
...

c
...

d
...

ANS: D
Only one new food is offered in a 4- to 7-day period to determine tolerance
...
The nurse is talking with a parent about tooth eruption
...
Lower central incisors
b
...
Lower lateral incisors
d
...

DIF: Cognitive Level: Knowledge REF: Page 392, Table 16-1
OBJ: 5 TOP: Development and Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12
...
What would the nurse expect to observe?
a
...
Grasping objects with palmar grasp
c
...
Beginning to use a spoon rather sloppily
ANS: C
The 9-month-old tries to creep, has developed pincer movement, and can grasp a spoon without keeping food
on it
...
What statement made by a parent indicates correct understanding of infant feeding?

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a
...

b
...

c
...

d
...

ANS: D
New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods
...
A mother is concerned because her 10-month-old is lethargic
...
Keep the infants room well lit
...
Rub the infants soles vigorously
...
Offer the infant a pacifier
...
Handle the infant slowly and gently
...
Move and handle infants slowly and
gently
...
The nurse discusses child-proofing the home for safety with the mother of a 9-month-old
...
I put covers on all of the electrical outlets
...
In the car, she rides in a front-facing car seat
...
There are locks on all of the cabinets in the house
...
I have a gate at the top and bottom of the stairs
...

DIF: Cognitive Level: Analysis REF: Page 403 OBJ: 17
TOP: Infant Safety KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
16
...

What does this behavior indicate the infant has developed?
a
...
A grasp reflex
c
...
The parachute reflex
ANS: A
By 1 year, the pincer-grasp coordination of index finger and thumb is well established
...
A parent is concerned because her infant has a diaper rash
...
Use commercial diaper wipes to clean the area
...
Apply a protective ointment on the area
...
Change the infants diaper less frequently
...
Keep the diaper area covered all of the time
...

DIF: Cognitive Level: Application REF: Page 396 OBJ: 6
TOP: Diaper Rash KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
18
...
She cries during diaper
changes and feedings
...
Play the radio or TV while you feed the infant
...
Put the infant in a room with sunlight
...
Wrap the infant snugly when you hold them
...
Change the infants position quickly
...

DIF: Cognitive Level: Application REF: Page 394-395
OBJ: 7 TOP: Infant Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
19
...
Ride a tricycle
...
Spend time in an infant swing
...
Play with push-pull toys
...
Read large picture books
...

DIF: Cognitive Level: Analysis REF: Page 404, Table 16-4
OBJ: 18 TOP: Infant Safety
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20
...
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
...

DIF: Cognitive Level: Analysis REF: Page 396 OBJ: 8
TOP: Sleep Patterns KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
Lifting the infant high in the air above her head

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b
...
Seating the infant in a stroller in an upright position
d
...

DIF: Cognitive Level: Comprehension REF: Page 387 OBJ: 3
TOP: Parachute Reflex KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22
...

What is the correct response?
a
...

b
...

c
...

d
...

ANS: C
Many pediatricians recommend iron-fortified formulas because maternal iron stores decrease by 6 months of
age
...
The nurse is assessing a 1-year-old infant in the pediatric office
...
Respiratory rate of 60 breaths per minute
b
...
Minimal verbalization
d
...
Increased respiratory rate can lead to
distress and should be reported immediately
...
Minimal
verbalization and fussy behavior are not emergency situations or abnormal for this age
...
A new mother is voicing concern she is breastfeeding her newborn too frequently
...
Every 2 to 3 hours
b
...
Every 6 to 8 hours
d
...
A
flexible but regular schedule that provides a rest period between feedings is best for the parent and infant
...
The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)?
(Select all that apply
...
Irritability
b
...
No predictable sleep-wake cycle
d
...
Effective parent bonding
ANS: A, B, C, D
Children who experience frequent hunger do not have effective parental bonding
...

DIF: Cognitive Level: Comprehension REF: Page 398, Table 16-2
OBJ: 3 TOP: Hunger KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26
...
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
...
Principles
of discipline for an infant include lowering the voice to say no firmly, removing the child from the situation,
distraction, and consistency
...
What should the teaching plan include about infant fall precautions? (Select all that apply
...
Remove all unsteady furniture
...
Keep crib rails up and in locked position
...
Steady infant with hand when on changing table
...
Use tray attachment on high chair as restraint
...
Keep infant seat on the floor
...
All other options are good precautions to prevent
an infant from a fall
...
The nurse is aware that the 7-month-old can signal feeding readiness by which action(s)? (Select all that
apply
...
Pulling spoon toward mouth
b
...
Pointing to food bowl
d
...
Manipulating finger foods
ANS: A, E

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The 7-month-old pulls the spoon toward his or her mouth and can manipulate finger foods
...

DIF: Cognitive Level: Comprehension REF: Page 398, Table 16-2 | Page 402, Figure 16-4
OBJ: 3 TOP: Feeding Skills
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
29
...
What immunizations against illness
should their child receive? (Select all that apply
...
Pertussis (whooping cough)
b
...
Diptheria
d
...
Polio
ANS: A, B, C, D, E
The first DPT, polio, and flu immunizations are given at the age of 2 months
...
What will the nurse take into consideration when educating parents regarding infant nutrition? (Select all
that apply
...
Cultural practices
b
...
Parental knowledge
d
...
Parent-child interaction
ANS: A, C, D, E
Parents have many concerns about feeding their infant during the first year of life
...
Assessment of parental knowledge; infant development, behavior, and readiness; parentchild interaction; and cultural and ethnic practices is important
...

DIF: Cognitive Level: Comprehension REF: Page 397, Box 16-1, Chapter 15
OBJ: 10 TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31
...
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
...
Sugar should be added sparingly
...
Foods may
be frozen in ice cube trays and defrosted for use
...
The nurse explains that the second process of self-mobility an infant learns is seen at the age of 9 months,
when the infant begins to ___________
...
At 9 months the infant begins
to creep, holding his or her trunk above the floor
...

DIF: Cognitive Level: Application REF: Page 389, Figure 16-3
OBJ: 3 TOP: Creeping KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33
...

ANS:
supine
The supine or side-lying position has been found to reduce possible aspiration and is believed to reduce the risk
of SIDS
...
______________ is characterized by periods of unexplained irritability and crying in a healthy, well-fed
infant
...

DIF: Cognitive Level: Knowledge REF: Page 395 OBJ: 1
TOP: Colic KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
35
...
Arrange the
development in the order from the simplest to the most complex
...
)
a
...
Grasps with thumb on one side and three fingers on the other
c
...
Thumb and forefinger hold object
e
...

DIF: Cognitive Level: Analysis REF: Page 388-389, Figure 16-3

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

OBJ: 3 TOP: Prehensile Development
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

154

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155

Chapter 17: The Toddler
MULTIPLE CHOICE
1
...
Has temper tantrums
b
...
Walks by holding onto furniture
d
...
The toddler who walks holding
onto furniture should be evaluated by a developmental specialist
...
What would the nurse assessing growth and development of a 2-year-old child expect to find?
a
...

b
...

c
...

d
...

ANS: A
The 2-year-old can jump with both feet
...

DIF: Cognitive Level: Comprehension REF: Page 407, Table 17-1
OBJ: 2 TOP: Jumping KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3
...
Is this normal? What
is the best explanation a nurse who has an understanding of toddler development might give?
a
...

b
...

c
...

d
...

ANS: B
Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler
...
The nurse observed three toddlers playing side by side with dolls
...
What type of play is this?
a
...
Parallel
c
...
Cooperative
ANS: B
Toddlers engage in parallel play
...

DIF: Cognitive Level: Comprehension REF: Page 418 OBJ: 11

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TOP: Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5
...
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
...

DIF: Cognitive Level: Application REF: Page 410 OBJ: 6
TOP: Limit Setting KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6
...
Insist that the child eat one food on the plate
...
Help the child wind down with a quiet activity before mealtime
...
Maintain a consistent eating schedule for the family
...
Serve the meal with a variety of interesting plates, cups, and utensils
...

DIF: Cognitive Level: Application REF: Page 413 OBJ: 9
TOP: Quiet Time KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7
...
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
...

ANS: C
A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving
sizes
...
The nurse is discussing toilet training with parents
...
Willing to sit on the potty for 15 to 20 minutes
b
...
Able to communicate that he or she is wet
d
...

DIF: Cognitive Level: Comprehension REF: Page 411, Table 17-4 | Page 412
OBJ: 8 TOP: Toilet Independence
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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9
...
Bicycle with training wheels
b
...
Wind-up toy
d
...

DIF: Cognitive Level: Application REF: Page 418 OBJ: 11
TOP: Toys and Play KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10
...
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
...

DIF: Cognitive Level: Application REF: Page 406 OBJ: 4
TOP: Offering Choices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11
...
What observation would lead the nurse to this conclusion?
a
...

b
...

c
...

d
...

ANS: B
A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it
...

DIF: Cognitive Level: Analysis REF: Page 415, 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
...
Hot dog sections
b
...
Popcorn
d
...
The toddler is at risk for choking on foods such as
grapes, hot dogs, and popcorn
...
Which finding would concern the nurse assessing vital signs on a 2-year-old?

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a
...
1 C (98
...
Pulse at 100 beats/min
c
...
Blood pressure of 90/60 mm Hg
ANS: C
In the toddler period, the respiratory rate decreases to 25 breaths/min
...
What would be an expected finding when assessing language development in a 2-year-old?
a
...
Use of two-word sentences
c
...
100% of speech is understandable
ANS: B
The 2-year-old should be using two-word sentences
...
The nurse is planning to explain the use of time-outs to the parent of a 3-year-old
...
3
b
...
10
d
...

DIF: Cognitive Level: Comprehension REF: Page 410 OBJ: 6
TOP: Guidance and Discipline KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16
...
Thank goodness she loves to
drink milk
...
Has your daughter been sick recently?
b
...
Has she become a fussy eater, too?
d
...
Too few solid foods can lead to dietary deficiencies of iron
...
How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to begin bladder
training?
a
...
2
c
...
4
ANS: B
If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective
...
Parents tell the nurse they are frustrated with their toddlers recent behavior and refusal to agree with
anything they ask of them
...
Negativism
b
...
Tantrums
d
...

Because toddlers are also egocentric, they come to believe that their negativism is absolute
...

DIF: Cognitive Level: Comprehension REF: Page 406 OBJ: 1
TOP: Negativism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
19
...
What is the expected weight gain for this age child?
a
...
2
...
3 times the birth weight
d
...

DIF: Cognitive Level: Comprehension REF: Page 406 OBJ: 2
TOP: Weight Prediction KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
20
...
Be at eye level with the child
...
Hold by the shoulders to keep the childs attention
...
Seat the child to focus on conversation
...
Speak in a firm strong voice
...

DIF: Cognitive Level: Comprehension REF: Page 410 OBJ: 2
TOP: Conversing with Toddler KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
Toddlers have a shorter attention span
...
Toddlers need more group play
...
Toddlers are less prone to environmental dangers
...
Toddlers require less outdoor space
...
Toddlers are more interested in parallel play
...
A 16-month-old child is attending a well-child visit at a pediatric clinic
...
Does not walk independently
b
...
Limited to single words
d
...
It is normal for a child this age to prefer finger
feeding and to be limited to single words
...

DIF: Cognitive Level: Comprehension REF: Page 407, Table 17-1
OBJ: 2 TOP: Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
23
...
)
a
...
Sturdy and stable
c
...
Made of plastic or fiberglass
e
...
The composition is not
important as long as it is stable
...
The nurse suggests offering which food(s) to support the toddlers desire to self-feed? (Select all that apply
...
Pureed foods
b
...
Foods served cold
d
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 413 OBJ: 9
TOP: Self-Feeding KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25
...
)
a
...
Increased capillary response for thermoregulation
c
...
Elevation in white blood cell count
e
...

DIF: Cognitive Level: Comprehension REF: Page 407 OBJ: 2
TOP: Physiological Changes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
26
...
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
...
Clinging to favorite possessions and repetitive
rituals are self-consoling behaviors for the toddler, particularly at bedtime and during separation from parents
...
Adults should attempt to control their own fears in the presence of young
children
...
Making fun of the
fear or shaming the child in front of others is detrimental to self-esteem
...
The nurse assessing a 2-year-old is satisfied to see that the present weight of the child is _____________
the birth weight
...

DIF: Cognitive Level: Comprehension REF: Page 406 OBJ: 2
TOP: Tripled Birth Weight KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28
...

ANS:
bowel, bladder
With the mature myelin, the toddler is able to translate neural impulses and respond in a significant manner
...

DIF: Cognitive Level: Comprehension REF: Page 407 OBJ: 8
TOP: Myelination KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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29
...

ANS:
egocentrism
Toddlers are egocentric in that they perceive their world only as it applies to them, such as MY mommy, MY
dog, MY car, MY house, MY street
...

DIF: Cognitive Level: Comprehension REF: Page 418, Table 17-1
OBJ: 2 TOP: Egocentrism KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30
...

ANS:
regression
Regression occurs when a situation causes the person to go back to a less mature manner of coping
...
The same regression frequently appears when a new infant is introduced to the
family circle, or when a traumatic event such as a death or divorce affects the family
DIF: Cognitive Level: Comprehension REF: Page 412 OBJ: 2
TOP: Toddler Regression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
31
...

ANS:
autonomy; shame and doubt
The toddler is in Eriksons stage of autonomy versus shame and doubt, which is based on a continuum of trust
established during infancy
DIF: Cognitive Level: Knowledge REF: Page 406 OBJ: 3
TOP: Eriksons Stages KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...

ANS:
Ritualism
Ritualism is when toddlers increase their sense of security by making compulsive routines of simple tasks
...
Put the developmental milestones in order from first achieved to last achieved
...
)
a
...
Holds a cup by the handle
c
...
Babbles

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e
...
Which statement best describes the 3-year-old child?
a
...
Aggressive, shows off
c
...
Talkative, inquisitive about the environment
ANS: C
Three-year-old children are helpful and can assist in simple household chores
...
The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis
...
This behavior indicates a normal curiosity about sexuality
...
Masturbation suggests the boy has an excessive fear of castration
...
It is usually a result of discomfort from a penile rash or irritation
...
The behavior is abnormal and the child should be referred for counseling
...

DIF: Cognitive Level: Comprehension REF: Page 424 OBJ: 9
TOP: Masturbation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3
...
So I can have shade over my sandbox
...
Because God made them that way
...
To hide behind when they are scared
...
For the squirrels to play in
...

DIF: Cognitive Level: Application REF: Page 421 OBJ: 1
TOP: Cognitive Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4
...
Setting the table with paper plates
b
...
Carrying glasses from the table to the sink
d
...

DIF: Cognitive Level: Application REF: Page 430 OBJ: 3
TOP: DevelopmentSafety KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5
...
What behavior will the nurse anticipate from this
child?
a
...
Will give the toy up and then not play anymore
c
...
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
...
A parent is concerned about her childrens reaction should their grandmother die
...
Children are unlikely to notice their grandmothers absence if no one reminds them
...
Young children often understand that other people die, but do not equate it with themselves
...
The childrens response will depend entirely on whether they have been acquainted with death before this
...
Children can understand the concept of a higher being much like adults can
...
They may realize that others
die, but they do not relate death to themselves
...
What is the most appropriate intervention when dealing with occasional aggression in a 4-year-old child?
a
...

b
...

c
...

d
...

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
...
A father is concerned about how long his preschool-age child will continue sucking his thumb
...
Most children will stop thumb-sucking naturally by school age
...
Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice
...
Consistently touching the childs fingers whenever he sucks his thumb is most effective
...
Thumb-sucking is detrimental to the eruption of the childs teeth and must be stopped as soon as possible
...

DIF: Cognitive Level: Application REF: Page 428 OBJ: 9
TOP: Thumb-Sucking KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9
...
Enjoying rough and tumble play
b
...
Following rules
d
...
The rules may be very strict or change as
the game progresses
...
The nurse is discussing preschoolers sexual curiosity with the parent
...
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 year old
...

DIF: Cognitive Level: Analysis REF: Page 424 OBJ: 9
TOP: Sexual Curiosity KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
11
...
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
...

DIF: Cognitive Level: Application REF: Page 431 OBJ: 14
TOP: Play KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12
...
Having imaginary friends is a sign that the child has low self-esteem
...
It is common for preschoolers to have imaginary friends
...
Preschoolers invent an imaginary friend when they feel overwhelmed
...
The best approach to dealing with an imaginary friend is to ignore them
...

DIF: Cognitive Level: Comprehension REF: Page 431, Nursing Tip
OBJ: 13 TOP: Imaginary Friend
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13
...
Applying an electric pad that gently shocks the child
b
...
Decreasing fluid intake after the evening meal
d
...

DIF: Cognitive Level: Application REF: Page 428-429
OBJ: 9 TOP: Enuresis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14
...
A board game
b
...
A large construction set
d
...

DIF: Cognitive Level: Application REF: Page 431 OBJ: 13
TOP: Play KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
15
...
Based on the
parents comment, what does the nurse suspect?
a
...
An expressive language delay
c
...
A potential hearing deficit
ANS: B
An expressive language delay is suspected when the child understands spoken language but is not talking
...
The parent of a 4 -year-old child tells the nurse, Bedtime is difficult
...

The nurse and the childs mother discuss options
...
Allow the child to put himself to bed when he is tired
...
Let the child read in his room until he falls asleep
...
Establish a bedtime routine and use it consistently
...
Tire him out with physical activity before bedtime
...

DIF: Cognitive Level: Application REF: Page 424 OBJ: 6
TOP: Bedtime Habits KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17
...
Water
b
...
Bodily harm

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168

d
...

DIF: Cognitive Level: Knowledge REF: Page 425 OBJ: 3
TOP: Fear KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18
...
Of what is this an example?
a
...
Artificialism
c
...
Centering
ANS: D
The tendency to concentrate on a single outstanding characteristic of an object while excluding other features
is known as centering
...
A 4-year-old child insists he has more money with a nickel than his father has with a dime
...
Egocentrism
b
...
Animism
d
...
A nickel is larger than a dime and therefore more valuable
...
What will children who are unable to express themselves with words often do?
a
...
Develop other methods of verbal communication
c
...
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
...
Which is an example of associative play?
a
...
Two children playing in a sand box, one building a wall and the other digging a hole
c
...
Two children playing with a coloring book, one coloring pictures and the other looking at pictures
ANS: A

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Associative play allows the preschoolers to use their enlarged vocabulary in play with other children to carry
on conversations and describe scenarios for each to play
...
The nurse is educating a group of preschool parents about the importance of safety
...
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
...
Preschool
children still require a good deal of indirect supervision to protect them from dangers that arise from their
immature judgment or social environment
...

DIF: Cognitive Level: Comprehension REF: Page 430 OBJ: 11
TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
23
...
What clinical classification of speech disorder does the nurse
suspect?
a
...
Expressive language delay
c
...
Articulation disorder
ANS: D
When parents are the only people to understand their preschool child, an articulation disorder is suspected
...
)
DIF: Cognitive Level: Application REF: Page 423 OBJ: 5
TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
24
...
)
a
...
Assume a role and act it out
c
...
Avoid magical thinking
e
...
Play employs the use of magical thinking
...
What developmental milestone(s) assist the 5-year-old boy toward developing his sexual identity? (Select

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170

all that apply
...
Begins to be less focused on his mother
b
...
Regresses to a more infantile level
d
...
Identifies with the parent of the same sex
ANS: A, D, E
Children of this age become less focused on the mother as the central person and begin to identify with the
parent of the same sex, forming a romantic attachment to the parent of the opposite sex
...
A little girl might say, Im going to marry my daddy
...
Which bedtime preparation rituals are the most appropriate for the nurse to suggest? (Select all that apply
...
Telling a story
b
...
Placing a glass of water at the bedside
d
...
Playing energetically
ANS: A, B, C, D
All options are soothing bedtime rituals except energetic playing, which would be stimulating and
counterproductive to sleep
...
The nurse points out what advantage(s) of a nursery school or preschool experience? (Select all that apply
...
Increasing self-confidence
b
...
Detecting adjustment problems
d
...
Playing experiences with other children
ANS: A, B, C, E
Nursery school increases self-confidence, group cooperation, social skills, and cooperative play
...
The child is usually toilet
trained prior to the start of preschool
...
Which major developmental tasks will the nurse expect a child to accomplish by the end of the preschool
years? (Select all that apply
...
Development of parallel play
b
...
Increased communication skills
d
...
Control of bodily functions
ANS: B, C, E
The major tasks of the preschool child include preparation to enter school, development of a cooperative type
of play, control of body functions, acceptance of separation, and increase in communication skills, memory,

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171

and attention span
...

DIF: Cognitive Level: Comprehension REF: Page 420 OBJ: 2
TOP: Major Developmental Tasks
...
When planning an activity for a 3-year-old, the nurse bases the plan on the average attention span of _____
minutes
...

DIF: Cognitive Level: Comprehension REF: Page 422, Table 18-1
OBJ: 3 TOP: Attention Span of Preschooler
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30
...

ANS:
therapeutic
Therapeutic play, whether at home or in a clinic or rehab center, is designed to retrain muscles, strengthen
muscles, or improve eye-hand coordination
DIF: Cognitive Level: Knowledge REF: Page 432 OBJ: 14
TOP: Therapeutic Play KEY: Nursing Process Step: N/A
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31
...

ANS:
discipline
Through discipline the parent gradually gives up behavior self-control to the child
...
____________ is a preschoolers idea that the world and all of its contents are created by people
...

DIF: Cognitive Level: Knowledge REF: Page 421 OBJ: 1
TOP: Artificialism KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33
...

ANS:

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Symbolic functioning
Symbolic functioning is seen in the play of children who pretend that an empty box is a fort; they create a
mental image to stand for something that is not there
...
Put the stages of separation anxiety in order from first to last
...
)
a
...
Regression
c
...
Protest
ANS:
D, C, A, B
The preschool child may feel abandoned by the parents and continues to be subject to separation anxiety
...

DIF: Cognitive Level: Comprehension REF: Page 432 OBJ: 3
TOP: Separation Anxiety KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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173

Chapter 19: The School-Age Child
MULTIPLE CHOICE
1
...
What will the nurse expect in regard to physical development of
this child?
a
...
Gain of 5 to 7 pounds per year
c
...
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
...

DIF: Cognitive Level: Knowledge REF: Page 435 OBJ: 3
TOP: Physical Growth KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
School-age children can concentrate on only one aspect of a situation
...
School-age children can think abstractly
...
School-age children are egocentric in their thinking
...
School-age children think logically and concretely
...

DIF: Cognitive Level: Comprehension REF: Page 434, Box 19-1
OBJ: 3 TOP: Cognitive Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
3
...
Heterosexual interest groups
b
...
Rigidly organized groups with complex rules
d
...

DIF: Cognitive Level: Analysis REF: Page 435 OBJ: 3
TOP: Social DevelopmentPlay KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4
...
What is the best experience for this child according to Eriksons theory?
a
...
Successful performance in Little League
c
...
Having a girlfriend
ANS: B
The child who is successful in activities will feel positively about himself or herself
...
The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent
nightmares
...
They are a normal extension of the childs fear of mutilation
...
They are an abnormal response to repressed feelings
...
They are a common result of latent sexuality
...
They are a side effect of overactivity and stimulation
...

DIF: Cognitive Level: Comprehension REF: Page 444, Table 19-3
OBJ: 3 TOP: Eight-Year-Old
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6
...
Handheld video game
b
...
Adventure book
d
...
At this age, the handheld
video game will offer nonaggressive competition
...
The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon be starting
first grade
...
We should put a stop to her thumb-sucking
...
Well have a talk about what school is like
...
We will let her walk to the bus stop by herself
...
Well have her meet some children who will be in her class
...

DIF: Cognitive Level: Application REF: Page 438, Patient Teaching
OBJ: 4 TOP: Parental Guidance for Starting School
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
8
...
What is the most
probable factor causing this behavior?
a
...

b
...

c
...

d
...

ANS: A
The 9-year-old child requires about 10 hours of sleep per night
...
A parent asked the nurse, At what age are children capable of assuming more responsibility for personal
belongings? What is the nurses best response based on knowledge of growth and development?
a
...
7 years
c
...
12 years
ANS: C
The 9-year-old is dependable and assumes more responsibility for personal belongings
...
The school nurse is preserving a tooth that was knocked out on the school playground
...
Wrap the tooth loosely in a clean cloth
...
Rinse the tooth with alcohol
...
Handle the tooth only by the crown
...
Place the tooth in a warm environment
...

DIF: Cognitive Level: Application REF: Page 439, Nursing Tip
OBJ: 7 TOP: Safety KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11
...
His 10-year-old brother has allergies to animal dander
...
What type of pet should the nurse suggest as the best choice?
a
...
An older unneutered dog that produces fewer allergens than a younger one
c
...
A poodle, which does not shed, making it a good choice for people with allergies
ANS: D
The poodle does not have a shed cycle and so it may be the least offensive pet for the allergic child
...
When asked about her activities, a 10-year-old girl responded, I like school
...
What does the nurse know these activities will help this child develop?
a
...
Industry
c
...
Intimacy
ANS: B
The school-age period is referred to by Erikson as the stage of industry
...

DIF: Cognitive Level: Application REF: Page 434 OBJ: 3
TOP: Psychosocial Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13
...


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Which statement made by the parent alerts the nurse to a potentially unsafe situation for this child?
a
...

b
...

c
...

d
...

ANS: A
Latchkey children are subject to a higher rate of accidents
...

DIF: Cognitive Level: Application REF: Page 439 OBJ: 4
TOP: Latchkey Children KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
14
...
What is the best nursing response to this parent?
a
...

b
...

c
...

d
...

ANS: D
The child cannot help such actions and should not be scolded for them because they are mainly a result of
tension
...
A seventh-grade girl tells the school nurse that her art teacher, a woman, is her hero
...
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
...
For the 11- to 12-year-old, hero
worship is a normal phenomenon
...
Which stage of cognitive development is a 9-year-old child in according to Piaget?
a
...
Preoperational
c
...
Sensorimotor
ANS: C
School-age children are in the concrete operations stage of cognitive development
...
What statement by an 11-year-old leads the nurse to determine he has moved from the mind set of

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egocentrism?
a
...

b
...

c
...
Im sorry
...

ANS: D
The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mindset
...
A school-age child becomes frustrated with a school assignment and says, I cant do this! What is the most
developmentally supportive response from the parent?
a
...
Allow the child to quit the effort
...
Call in older siblings to help
...
Finish the project for them
...
Quitting or
having someone else finish is detrimental to the development of industry
...
What is best for the nurse to suggest to the parents of an overweight 9-year-old to help prevent obesity?
a
...

b
...

c
...

d
...

ANS: C
Regular physical activity reduces weight
...
A parent confides in the school nurse that her 8-year-old twins argue and bicker constantly
...
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
...

DIF: Cognitive Level: Application REF: Page 440 OBJ: 3
TOP: Argumentative Behavior KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
What should the nurse be sure

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178

to do?
a
...

b
...

c
...

d
...

ANS: A
Using simple terms is essential but slang and street terms need to be clarified
...

DIF: Cognitive Level: Application REF: Page 436-437, Nursing Tip
OBJ: 7 TOP: Sex Education
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
22
...
What area of
development will the nurse indicate that school affects the least?
a
...
Social development
c
...
Cognitive development
ANS: C
Physical development is the least affected by school life
...
Schools have a profound influence on the
socialization of children, who bring to school what they have learned and experienced in the home
...

DIF: Cognitive Level: Application REF: Page 437 OBJ: 5
TOP: Impact of School Life KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE
23
...
)
a
...
Glad
c
...
Scared
e
...

DIF: Cognitive Level: Application REF: Page 443, Nursing Tip
OBJ: 3 TOP: Expression of Feelings
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
24
...

What information is accurate for the nurse to include? (Select all that apply
...
Participation in group activity increases
b
...
Thinking is logical
d
...
Understand cause and effect

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ANS: A, C, E
Piaget refers to the thought processes of the school age period as concrete operations
...

The egocentric view of the preschool child is replaced by the ability to understand the point of view of another
person
...

DIF: Cognitive Level: Comprehension REF: Page 434 OBJ: 2
TOP: Personality Development KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25
...
What guidelines should they be educated to follow? (Select all that apply
...
Ask for identification before letting someone in the house
...
Never accept rides with strangers
...
Keep doors locked
...
Do not enter house if door is ajar
...
Walk to and from school with friends
...
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
...
A 10-year-old child with disabilities is begging her parents for a dog
...
What benefits of pet
ownership should the nurse indicate? (Select all that apply
...
Decrease the need for physical therapy
b
...
Improve communication
d
...
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
...
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
...
Shy children often find pet
ownership eases the path to socialization with others who initiate contact because of the pet
...
The nurse advises the parents of a 6-year-old to try and ensure at least ______ hours of sleep daily for the
child
...


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DIF: Cognitive Level: Comprehension REF: Page 440 OBJ: 3
TOP: Sleep Needs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
28
...

ANS:
young, spayed
Young, neutered female dogs produce less allergens
...
When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse
cautioned the teacher to be alert for symptoms of ____________________ that can be carried by the reptiles
...

DIF: Cognitive Level: Comprehension REF: Page 447, Table 19-4
OBJ: 8 TOP: Salmonella KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30
...

ANS:
punishment
School-age children may come to believe their illness is a form of punishment for bad behavior or bad
thoughts
...
The nurse explains that the term _______________ refers to a sex role that incorporates both male and
female traits
...

DIF: Cognitive Level: Knowledge REF: Page 436 OBJ: 7
TOP: Sex Education KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
32
...

ANS:
6
At the age of 6, the first permanent teeth erupt: the 6-year molars
...
The _____________________________maintains that every sex education program should present the
topic from six aspects: biological, social, health, personal adjustment and attitudes, interpersonal associations,
and establishment of values
...
The nurse is assessing a 13-year-old boy
...
Development of axillary and facial hair
b
...
Enlargement of testicles
d
...

DIF: Cognitive Level: Knowledge REF: Page 453 | Page 454, Box 20-2
OBJ: 4 TOP: Physical Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
2
...
What would be the nurses most informative
response?
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
...
A parent comments that her adolescent daughter seems to be daydreaming a lot
...
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
...

This helps them to prepare for and cope with interactions with others
...
The nurse is planning a safety program for high school students
...
Firearms
b
...
Drowning
d
...


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DIF: Cognitive Level: Knowledge REF: Page 464 OBJ: 14
TOP: Safety KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
5
...
Which response represents an
effective problem-solving approach for his parents?
a
...

b
...

c
...

d
...

DIF: Cognitive Level: Application REF: Page 462, Health Promotion box
OBJ: 5 TOP: Parenting KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
6
...
What psychosocial task does the nurse understand is important
for the adolescent to develop?
a
...
A sense of industry
c
...
A sense of involvement
ANS: C
Psychosocial milestones that must be accomplished during adolescence include the five Isimage of self,
identity, independence, interpersonal relationships, and intellectual maturity
...
A 13-year-old girl tells the school nurse that she is getting fat, especially in her hips and legs
...
Many adolescents are unaware of proper nutrition
...
Adolescents of this age become less active and should eat fewer calories
...
Puberty is often preceded by fat deposits in these areas
...
As soon as menarche occurs, she will lose this excess weight
...
Fat is deposited in the hips, thighs, and
breasts, causing them to enlarge
...
The school nurse is planning a program for girls about the physical changes of puberty
...
10 years
b
...
14 years
d
...

DIF: Cognitive Level: Comprehension REF: Page 451 OBJ: 4
TOP: Physical Development KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
9
...
I set amounts he can earn for particular chores
...
I give him a certain amount of money for each day
...
I put money into his bank account each month
...
I told him to ask me when he needs money
...
The older adolescent is able to get a job
...

DIF: Cognitive Level: Comprehension REF: Page 458-459 | Page 461-462
OBJ: 8 TOP: DevelopmentResponsibility
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
10
...
Green, leafy vegetables
b
...
Nuts
d
...
Good vegetable sources include nuts,
legumes, and wheat germ
...
An adolescents parent comments, My son seems so preoccupied with his appearance these days
...
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
...

DIF: Cognitive Level: Application REF: Page 453, Table 20-1
OBJ: 14 TOP: Development
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
12
...
A cheeseburger and soda
b
...
Two sausage and egg breakfast sandwiches and orange juice
d
...

DIF: Cognitive Level: Comprehension REF: Page 463 OBJ: 12
TOP: Nutrition KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
13
...
What is developed during adolescence according to Piaget?
a
...
The ability to focus more on the past than present situations
c
...
The ability to consider hypothetical situations
ANS: D
According to Piaget, in the formal operations stage adolescents have the ability to think abstractly
...
A girl tells the nurse that she and her best friend belong to the popular clique
...
The nurse recognizes the girls statement as characteristic of what time period?
a
...
Middle adolescence
c
...
The entire adolescent period
ANS: A
Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent
...
The nurse is leading a discussion group with parents of adolescents
...
My opinion doesnt count anymore
...
It is unusual for adolescent boys
...
It is often more apparent in boys than girls
...
It is a normal phenomenon during adolescence
...
It is suggestive of feelings of low self-worth
...

DIF: Cognitive Level: Comprehension REF: Page 457-458
OBJ: 10 TOP: Peer Relationships
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
16
...
Social outlet
b
...
Platform for group think

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d
...

DIF: Cognitive Level: Comprehension REF: Page 453, Table 20-1 | Page 457-458
OBJ: 10 TOP: Peer Groups KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
17
...
Conceptual
b
...
Glandular
d
...

DIF: Cognitive Level: Knowledge REF: Page 451, Box 20-1
OBJ: 2 TOP: Freud KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
18
...
How would the nurse interpret this score?
a
...
Normal experimentation of the adolescent
c
...
Indication for referral for counseling
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
...
What does adolescent acne result from?
a
...
Oily skin
c
...
A poor diet
ANS: B
Adolescent acne is the result of overactive sweat glands and oily skin
...
The nurse suggests the use of I messages to communicate a parents feeling to an adolescent
...
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
...

DIF: Cognitive Level: Analysis REF: Page 462, Health Promotion box
OBJ: 14 TOP: I Statements
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21
...
What
is the best initial response from the nurse?
a
...

b
...
Age of first menstrual cycle varies
...
Do not worry about it
...
The first menstrual period is called the
menarche
...
It may occur as early as age 10 years
or as late as age 15 years
...
The nurse is documenting the pediatricians assessment of a female patient
...
What stage of development will the nurse document?
a
...
Stage 2
c
...
Stage 4
ANS: A
According to Tanners Stages of Sexual Maturity, Stage 1 (Preadolescent) is elevation of papilla only
...
The school nurse is educating high school students about guidelines to be followed when participating in
sports
...
I will eat carbohydrates before practice
...
I drink large amounts of fluid when working out
...
I wear protective gear every time I play sports
...
I avoid caffeine when participating in sports
...
Thirst is one guide
for intake
...
Carbohydrates that provide both
energy and other nutrients are best for athletes
...

DIF: Cognitive Level: Application REF: Page 463 OBJ: 13
TOP: Sport Guidelines KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
MULTIPLE RESPONSE

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24
...
)
a
...
Urge for independence
c
...
Intense libido
e
...

DIF: Cognitive Level: Comprehension REF: Page 450 OBJ: 11
TOP: Sources of Stress for the Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
25
...
)
a
...
Coffee and chocolate-covered donuts
c
...
Whole grain cereal and yogurt
e
...
Meals with a high sugar
content result in a soothing sleepy response
...

DIF: Cognitive Level: Application REF: Page 463 OBJ: 12
TOP: Nutrition KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26
...
)
a
...
Selection of a career
c
...
Obtaining a drivers license
e
...
Legal drinking age, drivers license,
and matriculation through high school are such signals
...

DIF: Cognitive Level: Comprehension REF: Page 464, Nursing Tip
OBJ: 9 TOP: Rites of Passage
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
27
...
Which concepts
should guide the nurse to base a reply? (Select all that apply
...
Homosexual behavior in adolescents is not uncommon
...
Homosexuality is a mental disorder
...
Adolescents often desire to explore alternative lifestyles
...
Homosexual tendencies should be addressed with counseling
...
Parents should seek a support group for parents of gays
...
Homosexual
activities are not uncommon in adolescence
...
The school nurse is discussing challenges of the adolescent years with a group of high school students in
health class
...
Developing intimacy
b
...
Searching for identity
d
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 450-451
OBJ: 3 TOP: Challenges KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
COMPLETION
29
...

ANS:
conformity
For all of the stress from coming of age as an individual in his own right, the adolescent also has an equal drive
for conformity
...
The nurse knows that an adolescent may find making a career choice difficult because there is less clarity
in ______________ roles
...

DIF: Cognitive Level: Comprehension REF: Page 451 OBJ: 11
TOP: Blurred Gender Roles KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
31
...

ANS:
15
A sunscreen with an SPF of at least 15 is recommended to block sun rays that cause cancer
...
______________ is frequently delayed in girls who are involved in activities that require a lean body and a
high level of physical activity
...

DIF: Cognitive Level: Comprehension REF: Page 453 OBJ: 4
TOP: Menarche KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
33
...

ANS:
asynchrony
The general appearance of the adolescent tends to be awkward, that is, long-legged and gangling; this growth
characteristic is termed asynchrony because different body parts mature at different rates
...
Which child would have the most difficulty in coping with separation from parents because of
hospitalization?
a
...
16-month-old child
c
...
7-year-old child
ANS: B
Separation anxiety occurs after age 6 months and is most pronounced in the toddler
...
A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago
...
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
...

DIF: Cognitive Level: Analysis REF: Page 471-472
OBJ: 3 TOP: Separation Anxiety
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3
...
A germ made me get sick
...
I got sick because I was mad at my brother
...
My tonsils are sick and they have to come out
...
I have a cast because I broke my leg
...

DIF: Cognitive Level: Application REF: Page 481 OBJ: 9
TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
4
...
In which stage of separation anxiety is the toddler?
a
...
Despair
c
...
Attachment
ANS: C
In the stage of denial or detachment, the child appears to deny the need for the parents and becomes
uninterested in their visits
...
The nurse must make a room assignment for a 16-year-old with cystic fibrosis
...
A 4-year-old child who had an appendectomy
b
...
A 15-year-old with type 1 diabetes mellitus
d
...
The adolescent
would do best with a roommate who is closest to his or her age and also lives with a chronic illness
...
The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling
...
Preschool children can be disruptive in the hospital environment
...
Seeing his younger sibling would probably frighten the preschooler and thus should be avoided
...
The sibling could view the infant from the doorway but not enter the room to prevent the spread of
microorganisms
...
The preschooler needs to visit his infant sister to reassure himself that she is all right
...
Their ability to cope is influenced by their age, experience,
and intactness of the family
...
A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his
favorite bottle
...
He is dealing with the anxiety of hospitalization by regressing
...
He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital
...
He is attempting to refocus the attention of the adults around him to avoid further painful procedures
...
He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they
have mastered them
...
They show their displeasure when illness restricts satisfaction of
their desires
...

DIF: Cognitive Level: Comprehension REF: Page 474-475
OBJ: 1 TOP: Regression KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
8
...
What is the best rationale
for this nursing intervention?
a
...
Providing a way for the child to express his feelings
c
...
Distracting the child from thinking about the pain

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193

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
...
What is the best suggestion by the nurse when parents ask, When is the best time to begin to prepare a 5year-old for surgery and hospitalization?
a
...
About 2 weeks before surgery
c
...
On the night before admission to the hospital
ANS: C
Parents should prepare children for procedures and hospitalization a few days in advance
...
The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM
...
Your mommy will be here around noon
...
Your mommy will be here when you have lunch
...
Mommy will be here very soon
...
Your mommy is coming in 4 hours
...
They understand time relationships through activities
in their experience, such as naptime and mealtimes
...
A 13-year-old girl has been hospitalized for the past week
...
Invasive procedures
b
...
Appearance
d
...

DIF: Cognitive Level: Comprehension REF: Page 482 OBJ: 11
TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
12
...
What is the nurses most appropriate response to this mother?
a
...
Im doing the very best job that I can with your child
...
Why dont you go have a cup of coffee? You are going to be exhausted if you dont take a break
...
Id love for you to share with me some of the special things you do for your child
...

DIF: Cognitive Level: Application REF: Page 476-477
OBJ: 5 TOP: The Parents Reaction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
13
...
Maybe I should just stay away
...
Perhaps you are right
...

b
...
This is a common reaction in children when they are separated from their
parents
...
It might be easier for your child if you would stay with him, but this decision is up to you
...
We take good care of him and he seems fine when you are not here
...
The child will revert to protest when the parent arrives for a visit
...
What should the nurse, preparing to collect an admission history from parents who have recently emigrated
from Russia, keep in mind?
a
...

b
...

c
...

d
...

ANS: C
In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation
...
Which nursing action would facilitate rapport with a child and the childs parents during the admission
process?
a
...

b
...

c
...

d
...

ANS: B
The nurse tries not to appear rushed
...

DIF: Cognitive Level: Application REF: Page 477-478
OBJ: 5 TOP: Nurses Role in Hospital Admission
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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195

16
...
Which technique is most appropriate to alleviate the childs distress?
a
...

b
...

c
...

d
...

ANS: B
Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help
reduce anxiety and pain
...
A 4-year-old begins to cry when his mother tells him it is time for his operation
...
On which particular fear of the preschooler does the nurse base this understanding?
a
...
Restricted mobility
c
...
Invasive procedures
ANS: D
The preschool-age child is afraid of bodily harm, particularly invasive procedures
...
What statement by the parent of a hospitalized toddler leads the nurse to determine the parent understands a
hospitalized toddlers need for transitional objects?
a
...

b
...

c
...

d
...

ANS: A
The use of a transitional object such as a blanket or a favorite toy promotes security
...
An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur
...
Loss of control
b
...
Shame and guilt
d
...

DIF: Cognitive Level: Application REF: Page 482 OBJ: 10
TOP: The Hospitalized School-Age Child
KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

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20
...
What advantage of fentanyl will the nurse explain?
a
...

b
...

c
...

d
...

ANS: B
Fentanyl is a drug useful for all ages because of its rapid onset and brief duration
...
The nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child
...
Clinical pathway
b
...
Holistic care approach
d
...

DIF: Cognitive Level: Comprehension REF: Page 478 OBJ: 8
TOP: Clinical Pathway KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
22
...
What is the nurses most helpful response?
a
...

b
...
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
...

ANS: C
Addiction is rare in children
...
The nurse is preparing to start an IV on an infant admitted to the pediatric unit
...
Involve the parents
...
Provide a simple explanation to the child
...
Let the child examine the equipment
...
Suggest coping techniques
...
Providng a simple
explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate
interventions for an infant
...
The pediatric nurse is caring for child that weighs 15 kilograms and calls the physician for an order for
Acetaminophen for pain control
...
100 mg
b
...
225 mg
d
...
The
maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours
...
What will the nurse include when documenting the discharge of a pediatric patient? (Select all that apply
...
Time of discharge
b
...
Condition of the child
d
...
Instructions that were given to physician
ANS: A, B, C, D
Information that should be included in the discharge note include time of discharge, adults accompanying the
child and relationship to child, condition of the child, and method of transportation
...

DIF: Cognitive Level: Application REF: Page 484, Legal and Ethical Considerations box
OBJ: 12 TOP: Discharge Documentation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
26
...

What advantage(s) does this type of facility have to offer? (Select all that apply
...
Lower cost
b
...
Reduction of parent-child separation
d
...
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
...
What are the basic fears of a young child being hospitalized? (Select all that apply
...
Separation
b
...
Pain
d
...
Body intrusion
ANS: A, C, E

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Small children all share the same basic fears relative to hospitalization, which are separation from family, pain,
and body intrusion or mutilation
...
What information will the nurse include when taking a developmental history? (Select all that apply
...
Previous experience with hospitalization
b
...
History of illness
d
...
Childs nickname
ANS: A, B, E
The developmental history has information about the child and the childs developmental and cultural needs and
personal preferences
...

DIF: Cognitive Level: Application REF: Page 478 OBJ: 7
TOP: Developmental History KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
29
...
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
...
For a toddler, model
the behavior desired (i
...
, opening the mouth), tell the child it is okay to yell if the treatment or procedure is
uncomfortable, and use distractions
...

DIF: Cognitive Level: Application REF: Page 480 OBJ: 7
TOP: Promoting a Positive Experience KEY: Nursing Process Step: Intervention
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
30
...
What should they
expect to see when visiting the pediatric unit? (Select all that apply
...
Nurses wearing all white
b
...
Availability of a playroom
d
...
Colored bedding
ANS: C, E
The childrens hospital unit differs in many respects from adult divisions
...
A cheerful, casual atmosphere helps to bridge the gap
between home and hospital and is in keeping with the childs emotional, developmental, and physical needs
...
The physical structure of the unit includes furniture of the proper height for the
child, soundproof ceilings, and color schemes with eye appeal
...

DIF: Cognitive Level: Knowledge REF: Page 470-471

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OBJ: 2 TOP: Health Care Delivery Settings/Pediatric Unit
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
COMPLETION
31
...

ANS:
correct
All misconceptions that a youngster has about procedures should be corrected
...
A(n) _______________ ______________ is a person under the age of 18 who can legally sign for consent
for medical treatment for themselves or their children
...

DIF: Cognitive Level: Knowledge REF: Page 483 OBJ: 1
TOP: Emancipated Minor KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
33
...

ANS:
Respite care
Respite care provides trained workers who come into the home for brief periods to relieve parents of the
responsibility of caring for the child
...
What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant?
a
...
Apical
c
...
Femoral
ANS: B
Apical pulses are advised for children under age 5 years
...
The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on
the child
...
Give the medication after confirming the childs name from the foot of the crib
...
Ask the charge nurse to give the medicine
...
Confirm the identity with the charge nurse, make a new bracelet, and give the medicine
...
Delay the medication until the admissions office can supply a new ID bracelet
...
All patients should be identified before treatment
...
The nurse instructed an adolescent female about collecting a clean-catch urine specimen
...
I should wash my perineum with soap and water, then begin to urinate
...
I clean the perineum from front to back with an antiseptic wipe before I urinate
...
Ill collect the first stream of urine in a sterile container
...
I will discard the first void and collect a freshly voided specimen 30 minutes later
...

DIF: Cognitive Level: Analysis REF: Page 497 OBJ: 2
TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4
...
Mix the medication with chocolate milk
...
Tell the child that the medication is candy
...
Give the medication quickly if the child is crying
...
Offer the child fruit juice after the medication is swallowed
...
Medications should not be mixed with food or drinks with important nutrients such as milk
because the child may develop distaste for it
...
A parent tells the nurse, Im not sure how to give this medicine to my infant
...
Pour the medication into a small cup and allowing the infant to drink it
...
Place the medication in a nipple and having the infant suck the nipple
...
Use an oral syringe and placing the medication in the side of the infants mouth
...
Administer the medication with a dropper onto the back of the infants tongue
...
The syringe is
placed midway back, at the side of the mouth
...
Gentamicin ear drops are prescribed for a 4-year-old child
...
Up and back
b
...
Up and out
d
...

DIF: Cognitive Level: Application REF: Page 503, Skill 22-8
OBJ: 10 TOP: Administering Ear Drops
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7
...
The thermometer probe is blunt and wide
...
It takes a brief time to register
...
The tympanic membrane shares circulation with the hypothalamus
...
The tympanic membrane and the brain have the same temperature
...

DIF: Cognitive Level: Knowledge REF: Page 495 OBJ: 4
TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8
...
Discard the residual and increase the volume of feeding by the amount of residual
...
Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding
...
Refill the syringe with formula after it has completely emptied
...
Position the child on the right side after a feeding
...

DIF: Cognitive Level: Application REF: Page 515, Skill 22-10
OBJ: 13 TOP: Enteral Feedings
KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Physiological Integrity: Reduction of Risk
9
...
Mummy
b
...
Jacket
d
...

DIF: Cognitive Level: Comprehension REF: Page 488 | Page 489, Skill 22-1
OBJ: 12 TOP: Restraining the Infant
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
10
...
Hourly
b
...
Every 3 hours
d
...

DIF: Cognitive Level: Knowledge REF: Page 505 OBJ: 12
TOP: Administering Parenteral Medications
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11
...
The drug is supplied
as a unit dose of 600,000 units in a 5-mL vial
...
1
...
1
...
1
...
1
...
25 mL
This dose would have to be given in divided doses as only 0
...

DIF: Cognitive Level: Analysis REF: Page 509, Medication Safety Alert
OBJ: 9 TOP: Administering Injections
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
12
...
Suction for two to three breaths
...
Clear the catheter with water after suctioning for reuse
...
Apply suction for no more than 15 seconds
...
Establish a regular schedule for suctioning
...

DIF: Cognitive Level: Application REF: Page 516 OBJ: 15

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TOP: Respiration KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
13
...
Six to 10 midsternal thrusts
b
...
Five chest thrusts followed by five back blows
d
...

DIF: Cognitive Level: Knowledge REF: Page 519 OBJ: 2
TOP: Management of Airway Obstruction
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14
...
What is the nurses most effective response?
a
...
It is over before you know it
...
Yes
...

c
...
Would you like to see the syringe?
d
...
Your mom and I are going to hold you to help you be still
...

DIF: Cognitive Level: Application REF: Page 504 OBJ: N/A
TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
15
...
Ventrogluteal muscle
b
...
Deltoid muscle
d
...

DIF: Cognitive Level: Application REF: Page 503 OBJ: 11
TOP: Administering Injections KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
16
...
Faster metabolism in the liver
b
...
Immature kidney function
d
...

DIF: Cognitive Level: Comprehension REF: Page 500 OBJ: N/A
TOP: Physiological Responses to Medication
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

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17
...
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
...
The diaper should be cloth, or the infant should be left
undiapered on a cloth pad
...
Which observation on entering the hospital room lets the nurse know that there is a need for the parents to
receive safety education to prevent unintentional injury?
a
...

b
...

c
...

d
...

ANS: B
Disposable diapers and supplies must be kept out of the infants reach to prevent accidental suffocation
...
A 9-year-old child is preparing for a lumbar puncture
...
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
...

DIF: Cognitive Level: Application REF: Page 499, Figure 22-7 A
OBJ: 8 TOP: Collecting SpecimensLumbar Puncture
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20
...
What will the nurse expect the childs daily urinary output to be?
a
...
500 to 600 mL
c
...
700 to 1000 mL
ANS: C
The average daily excretion of urine for a 4-year-old child is 600 to 700 mL
...
An infants dry diaper weighs 2
...
The wet diaper weighs 47 grams
...
47 mL
b
...
5 mL
c
...
5 mL
d
...
5 mL
ANS: B
Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper
...
47 2
...
5 grams = 44
...

DIF: Cognitive Level: Analysis REF: Page 513, Nursing Tip
OBJ: 4 TOP: Collecting SpecimensUrine Output
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22
...
What would be the best example provided by the nurse?
a
...
Green, leafy vegetables
c
...
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
...
The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital
...
Toddler with an axillary temperature of 99 F
b
...
Infant pulse rate of 100 beats per minute
d
...
An axillary temperature of 99
F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments
...
A 15-year-old patient returns to the pediatric unit following a lumbar puncture
...
Left side-lying
b
...
Prone
d
...

DIF: Cognitive Level: Application REF: Page 499 OBJ: 2
TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
MULTIPLE RESPONSE
25
...
)
a
...
Risks associated with the procedure
c
...
That the document must be signed and witnessed
e
...
It also establishes that the patient, parent, or legal guardian understands what they have been
told; the document should be signed and witnessed
...
Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all
that apply
...
Insulin
b
...
Vasodilators
d
...
Anticoagulants
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
...
A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F
...
)
a
...

b
...

c
...

d
...

e
...

ANS: B, C, E
When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the
child to cuddling, alertness, hydration, sociability, and quality of cry
...
Because dehydration is a common problem in infants
and children, skin turgor should be assessed
...
Rectal temperatures are not recommended for
pediatric patients
...
What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all
that apply
...
Age
b
...
Vital signs
d
...
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
...
The nurse is searching through several blood pressure cuffs to find a cuff that is the appropriate size for her
small patient
...

ANS:
two thirds
No matter the age of the patient, for the blood pressure cuff to provide an accurate reading it should cover two
thirds of the upper arm
...

DIF: Cognitive Level: Application REF: Page 492, Medication Safety Alert
OBJ: 4 TOP: Selection of Blood Pressure Cuff
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30
...

ANS:
8:30 AM
Periods of NPO should not exceed 4 to 6 hours for pediatric clients because they can become dehydrated very
quickly
...
The order reads, Give ampicillin oral suspension 400 mg PO every day
...
The nurse will give a dose of ______ mL
...
The physician has ordered phenytoin syrup 20 mg PO bid for a child who weighs 15 pounds
...
The safe daily dose of this medication is _____ mg
...
8 kilograms; 6
...
After instilling nose drops, the nurse will keep the infant in the head down position for at least _________
seconds
...

DIF: Cognitive Level: Comprehension REF: Page 502, Skill 22-7
OBJ: 10 TOP: Nose Drops KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
34
...

ANS:
hypothermia
Children in mist tents are at risk for hypothermia because of the high humidity and the cooled oxygen
...
The bed linens should be changed frequently as
they absorb moisture from the tent as well
...
An ________________________ implies that the parent or legal guardian is capable of understanding
information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to that
procedure
...

DIF: Cognitive Level: Knowledge REF: Page 486 OBJ: 1
TOP: Informed Consent KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
36
...

ANS:
anus, perineum
Begin by applying the urine collector to the tiny area of skin between the anus and the perineum
...

DIF: Cognitive Level: Knowledge REF: Page 498, Skill 22-5
OBJ: 7 TOP: Urine Specimen Collection
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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Chapter 23: The Child with a Sensory or Neurological Condition
MULTIPLE CHOICE
1
...
Why are infants
more susceptible to otitis media?
a
...

b
...

c
...

d
...

ANS: D
An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle
ear
...
What statement by a patients mother leads the nurse to determine she understands instructions about
administering an oral antibiotic for otitis media?
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
...
Which situation would cause the nurse to suspect a hearing impairment?
a
...
15-month-old toddler who is babbling
c
...
24-month-old toddler who communicates by pointing
ANS: D
The child who is not making verbal attempts by 18 months should undergo a complete physical examination
...
What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?
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
...
What would the nurse include when planning postoperative teaching for a child who has had a
tympanostomy with insertion of tubes?
a
...
Giving over-the-counter decongestants
c
...
Cleaning the ear canal with cotton-tipped applicators
ANS: C
After a tympanostomy, care should be taken to avoid getting water in the ears
...
What assessment made by the school nurse would lead to the suspicion of strabismus?
a
...
Child covers one eye to read the chalkboard
c
...
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
...

DIF: Cognitive Level: Analysis REF: Page 530-531
OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
7
...
Patching the good eye to force the brain to use the affected eye
b
...
Using glasses that will slightly blur the image for the good eye
d
...
Treatment includes patching the good
eye and using glasses to correct refractive errors
...
What assessment does the school nurse recognize as the cardinal sign of a hyphema?
a
...
A yellow-white reflex on the pupil
c
...
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
...
The nurse is planning to teach parents about prevention of Reyes syndrome
...
Use aspirin instead of acetaminophen for children with viral illness
...
Advise parents to have their children immunized against Reyes syndrome
...
Avoid giving salicylate-containing medications to a child who has viral symptoms
...
Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy
...

DIF: Cognitive Level: Application REF: Page 533 OBJ: 8
TOP: Reyes Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10
...
Respirations drop from 18 to 14 breaths/min
b
...
Sudden vomiting without effort
d
...
A 5-month-old child who sleeps after eating is normal
...
What does the nurse explains to parents of a child with febrile seizures?
a
...
3 C (101 F)
...
They can be prevented by anticonvulsant medication
...
They usually lead to the development of epilepsy
...
They occur when the temperature rises quickly
...
8 C (102 F)
...
A parent reports that her child has begun to do poorly at school and experiences episodes where he appears
to be staring into space
...
Absence
b
...
Myoclonic
d
...

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2
OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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13
...
When should the
nurse should call 911?
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
...
What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?
a
...

b
...

c
...

d
...

ANS: B
During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury
...
A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds
...
Restlessness
b
...
Nausea
d
...

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2
OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16
...
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
...
Dilantin frequently causes
drowsiness and should be given with meals at the same time each day
...
The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits

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jerky movements with his arms as he tries to eat
...
Athetoid
b
...
Spastic
d
...

DIF: Cognitive Level: Comprehension REF: Page 544, Table 23-4
OBJ: 12 TOP: Cerebral Palsy
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18
...
Irregular respirations
b
...
Slight drop in blood pressure
d
...

DIF: Cognitive Level: Application REF: Page 536 OBJ: 9
TOP: Meningitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity
19
...
How does the nurse identify this posture?
a
...
Decorticate
c
...
Opisthotonos
ANS: C
In decerebrate posturing, arms are extended along the side of the body and hands are pronated
...

DIF: Cognitive Level: Application REF: Page 550, Figure 23-13
OBJ: 15 TOP: Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
20
...
Apply cool compresses to the affected eye several times a day
...
Instill topical steroid eye drops for 1 week
...
Clear drainage from the inner to the outer aspect of the eye
...
Keep the eye patched until the inflammation resolves
...

DIF: Cognitive Level: Application REF: Page 532 OBJ: N/A
TOP: Conjunctivitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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21
...
Which nursing
assessment suggests the child has a concussion?
a
...
Complaining of a stiff neck
c
...
Pupils react sluggishly to light
ANS: C
A concussion is a temporary disturbance of the brain that is immediately followed by a period of
unconsciousness
...

DIF: Cognitive Level: Analysis REF: Page 548-552
OBJ: 16 | 17 TOP: Head Injury KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22
...
Her parents report that for the past few weeks
she has had headaches, with vomiting, that are worse in the morning
...
Meningitis
b
...
Brain tumor
d
...
Most tumors create increased
intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures
...
The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type
B
...
Encephalitis
b
...
Bacterial meningitis
d
...
influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial
meningitis
...
The nurse is caring for a 3-year-old with a head injury
...
Temperature increase from 37
...
7 C (100 F)
b
...
Increase in respirations
d
...

DIF: Cognitive Level: Comprehension REF: Page 552 OBJ: 14 | 17

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TOP: ICP KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25
...
How will this disorder most likely be corrected?
a
...
Corrective lenses
c
...
Surgery
ANS: B
In nonparalytic strabismus the refractory error is usually corrected with eyeglasses
...
Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they
implement in dealing with various challenges
...
We dress our son every morning for school
...
Our son participates in the Special Olympics every year
...
Our son attends play therapy at a center close to home
...
We attend a support group once a week
...
Caregivers should not take over
projects because of their own need to assist or speed up the process
...
What would the nurse include in teaching when preparing to teach parents about air travel instructions to
prevent barotrauma in infants?
a
...
Omitting the meal just before takeoff
c
...
Applying ear drops before takeoff
ANS: C
Encouraging an infant to swallow reduces the pressure in the ears during descent
...
Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6month-old child? (Select all that apply
...
Hypersensitivity to noise
b
...
Reddened ear canal
d
...
Temperature of 39
...


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DIF: Cognitive Level: Comprehension REF: Page 526, 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
29
...
)
a
...
Language development
c
...
Personality development
e
...

DIF: Cognitive Level: Comprehension REF: Page 527 OBJ: 3
TOP: Hearing Impairment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30
...
)
a
...
Provision of brightly lit room
c
...
Preparation for spinal tap
e
...

DIF: Cognitive Level: Application REF: Page 537 OBJ: 9
TOP: Nursing Care of Child with Meningitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
31
...
)
a
...
Current dose of antispasmodic medication
c
...
Level of consciousness following seizure
e
...
Reporting of medication regimen is not
necessary
...
The nurse is educating parents on prevention of eyestrain in their 5-year-old child
...
)
a
...

b
...

c
...


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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
...
Chairs and desks must be of the proper height
...
The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow
Coma Scale
...
1
b
...
3
d
...

DIF: Cognitive Level: Application REF: Page 553, Table 23-6
OBJ: 18 TOP: Neurological Monitoring/Infants
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
34
...
What priorities of care will be implemented?
(Select all that apply
...
Parental education regarding prevention
b
...
Cardiovascular support
d
...
Adequate cerebral oxygenation
ANS: B, C, D, E
Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral
oxygenation are priorities of care
...

DIF: Cognitive Level: Comprehension REF: Page 553-554
OBJ: 19 TOP: Near-drowning
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
COMPLETION
35
...

ANS:
decorticate
Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet
...

DIF: Cognitive Level: Comprehension REF: Page 550 OBJ: 15
TOP: Decorticate Posturing KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
36
...

ANS:
nuchal rigidity
Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal rigidity
...
The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the
__________________ nerve
...
It is also responsible for tongue
movement
...
__________________ occurs when there is a change in the atmospheric pressure between the internal body
systems and the surrounding environment
...

DIF: Cognitive Level: Knowledge REF: Page 529 OBJ: 1
TOP: Barotrauma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection

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Chapter 24: The Child with a Musculoskeletal Condition
MULTIPLE CHOICE
1
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 568 OBJ: 11
TOP: Legg-Calv-Perthes Disease KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2
...
Position in high Fowlers position
...
Assist the child to be pulled up in bed
...
Keep childs heel on the bed surface
...
Maintain childs feet against the foot of the bed
...
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
...
What will the nurse include when caring for a child in Bucks extension?
a
...
Keeping the weights in contact with the floor
c
...
Releasing the weights on a schedule
ANS: C
The skin exposed to frequent friction may break down
...
The nurse is reviewing the characteristics of Ewings sarcoma
...
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
...
Amputation of the affected extremity is
not recommended
...

DIF: Cognitive Level: Comprehension REF: Page 569 OBJ: N/A

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TOP: Ewings Sarcoma KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
5
...
Ambulates by holding onto furniture
b
...
Falls frequently and is clumsy
d
...

DIF: Cognitive Level: Knowledge REF: Page 567 OBJ: 10
TOP: Duchennes Muscular Dystrophy KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6
...
The child has a temperature of 38
...
What type of
juvenile rheumatoid arthritis do these findings suggest?
a
...
Enthesitis
c
...
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
...
The nurse is providing instructions about how to treat a sprained ankle
...
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
...
The principles of managing soft tissue injuries are rest, ice,
compression, and elevation
...
How does Russell traction provide adequate skin traction?
a
...
Does not interfere with range of motion
c
...
Supplies continuous pull in two directions
ANS: D
Russell traction is skin traction, similar to Bucks, with a sling positioned under the knee, which prevents
subluxation of the tibia
...


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DIF: Cognitive Level: Comprehension REF: Page 560 OBJ: 6
TOP: Russell Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9
...
How long does it take for the toe to
regain color if adequate perfusion is assessed?
a
...
4 seconds
c
...
6 seconds
ANS: A
Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion
...
The parent of a child with osteomyelitis asks why his child is in so much pain
...
Pressure of inelastic bone
b
...
The cast applied on the extremity
d
...
Inflammation produces an exudate that collects under the marrow
and cortex of the bone
...

DIF: Cognitive Level: Comprehension REF: Page 566-567
OBJ: N/A TOP: Osteomyelitis
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11
...
How long will the nurse indicate that antibiotic therapy will
probably last?
a
...
6 weeks
c
...
3 months
ANS: B
Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks
...
What finding would the nurse assessing the neurovascular status of a child in Russell traction report
immediately?
a
...
Capillary refill less than 3 seconds
c
...
Bluish coloration of skin
ANS: D
Cyanosis or pallor noted in an extremity is an indication of circulatory impairment
...
A 13-year-old girl is diagnosed with functional scoliosis
...
Juvenile rheumatoid arthritis
b
...
Heredity
d
...

DIF: Cognitive Level: Comprehension REF: Page 570-571
OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14
...
Ask the child to bend forward at the waist and observe the childs back for asymmetry
...
Observe the gait while the child is walking forward heel to toe
...
Have the child flex the knees and look for uneven knee height
...
Look at the childs shoulders and hips while fully clothed
...

DIF: Cognitive Level: Application REF: Page 570-571
OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15
...
Neurovascular checks are done frequently
...
Bandages are wrapped tightly
...
The child is restrained from rolling over
...
The childs buttocks are resting on the bed
...

DIF: Cognitive Level: Application REF: Page 562 OBJ: 7
TOP: Traction: Volkmanns Ischemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
16
...
Wearing splints at night to prevent extension contractures
b
...
Taking a warm tub bath the evening before
d
...

DIF: Cognitive Level: Application REF: Page 569 OBJ: 12
TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17
...
Wear the brace directly against the skin
...
Wear the brace over regular clothing
...
Wear the brace over a T-shirt 23 hours a day
...
Remove the brace before sleeping
...

DIF: Cognitive Level: Application REF: Page 570 OBJ: 13
TOP: Scoliosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18
...
Red, green, and yellow bruises on his body
b
...
A broken arm last year, and the child being described as accident-prone
d
...
Different colors of bruises indicate that injuries have not all
occurred at the same time
...

DIF: Cognitive Level: Analysis REF: Page 575, 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
...
She screams in pain
when she raises herself onto the bedpan
...
Pain resulting from tissue trauma
b
...
Altered growth and development related to separation from family
d
...

DIF: Cognitive Level: Analysis REF: Page 565, NCP 24-1
OBJ: 7 TOP: The Child with a Fracture in Traction
KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20
...
Has inward-turned knees while standing
b
...
Appears to have flat feet
d
...

DIF: Cognitive Level: Analysis REF: Page 557 OBJ: 3
TOP: Assessment of the Musculoskeletal System
KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
21
...
A childs bones are less porous than adult bone
...
A childs bones are covered by a thicker periosteum
...
A childs bones are not affected by bone overgrowth
...
A childs bones have faster callus formation
...

DIF: Cognitive Level: Knowledge REF: Page 560 OBJ: 2
TOP: Differences Between the Child and Adult
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22
...
Which
observation requires a nursing intervention?
a
...

b
...

c
...

d
...

ANS: A
Bucks traction is dependent on the child as a counterweight
...

DIF: Cognitive Level: Application REF: Page 560 OBJ: 7
TOP: Bucks Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
23
...
2 days
b
...
6 days
d
...

DIF: Cognitive Level: Comprehension REF: Page 575, Safety Alert
OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24
...
What type of
fracture would be the most likely to alert the nurse to the possibility of physical abuse?
a
...
Compound fracture
c
...
Greenstick fracture
ANS: C
A spiral fracture of the femur is caused by a forceful twisting motion
...

DIF: Cognitive Level: Comprehension REF: Page 560 OBJ: 5
TOP: Fractures/Child Abuse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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25
...
Risk for altered peripheral tissue perfusion
b
...
Knowledge deficit
d
...
Neurovascular checks are an assessment priority
...
A child is sent to the school nurse for assessment because she comes to school every day disheveled,
unbathed, and hungry
...
What do these
finding indicate?
a
...
Physical abuse
c
...
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
...
Which assessment performed by a nursing student performing a neurovascular check alerts the instructor
that further education is necessary?
a
...
Capillary refill
c
...
Pupils
ANS: D
Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement
...

DIF: Cognitive Level: Comprehension REF: Page 563 OBJ: 8
TOP: Neurovascular Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
28
...
)
a
...
High self-esteem
c
...
Overwhelming responsibility
e
...

DIF: Cognitive Level: Comprehension REF: Page 573, Health Promotion box
OBJ: 15 TOP: Child Abuse Triggers

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KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
29
...
)
a
...
Decrease muscle spasm
c
...
Align two bone fragments
e
...
Traction can also align broken bones and
decrease muscle spasm
...

DIF: Cognitive Level: Comprehension REF: Page 560-561
OBJ: 7 TOP: Traction KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30
...
)
a
...

b
...

c
...

d
...

e
...

ANS: C, D
The limb should be warm, and capillary refill should be less than 3 seconds
...
How does the pediatric skeletal system differ from that of the adult? (Select all that apply
...
Lower mineral content
b
...
Open epiphyses
d
...
Greater strength
ANS: A, C, E
The childs skeletal system has less mineral content, greater porosity, open epiphyses, greater bone strength,
and a thicker periosteum
...
The nurse explains that Bryants traction is reserved for children who weigh less than _____ pounds
...
Greater weight would cause excessive counterbalance and injury to soft tissues
...
The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weightbearing activities during treatment with radiation to reduce the risk of a(n) _______________ fracture
...
Excessive or vigorous weight bearing can
cause a pathological fracture of the compromised bone
...
The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to
a standing position
...

ANS:
Gowers
Gowers maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body
erect
...
The nurse recognizes the signs of ____________________ syndrome in a child in 90-90 traction when the
toes are pale and edematous and have a very slow capillary refill
...

Compartment syndrome occurs when the attendant edema from the injury or the traction compromises the
circulation
...

DIF: Cognitive Level: Comprehension REF: Page 563 OBJ: 7
TOP: Compartment Syndrome KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36
...

ANS:
coining
Some Vietnamese place heated coins on the body to cure disease
...

DIF: Cognitive Level: Comprehension REF: Page 575 OBJ: 16
TOP: Cultural Practices: Coining KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
37
...


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ANS:
Torticollis
Torticollis (tortus, twisted, and collium, neck) is a condition in which neck motion is limited and the cervical
spine is rotated because of shortening of the sternocleidomastoid muscle
...

DIF: Cognitive Level: Knowledge REF: Page 569 OBJ: 1
TOP: Torticollis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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Chapter 25: The Child with a Respiratory Disorder
MULTIPLE CHOICE
1
...
Acetaminophen and plenty of fluids
b
...
Penicillin until his sore throat is gone
d
...

DIF: Cognitive Level: Comprehension REF: Page 580 OBJ: N/A
TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
2
...
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
...
The humidity liquefies secretions and reduces spasm
...
The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A)
...
Bleeding from the surgical site
b
...
Sore throat from postnasal drip
d
...
Blood trickling down the back of the childs
throat could cause frequent swallowing
...
What is the best choice for fluid replacement that the nurse can offer a child who has just had a
tonsillectomy?
a
...
Chocolate milk
c
...
Cola drink
ANS: A
Small amounts of clear liquids can be offered to the child
...
A popsicle is usually well-tolerated
...
When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the
nurse immediately report?
a
...
Heart rate decrease from 110 to 100 beats/min
c
...
Oxygen saturation of 90%
ANS: C
A quiet chest after assessment of wheezing indicates occlusion of air pathways and impending respiratory
arrest
...

DIF: Cognitive Level: Analysis REF: Page 584 OBJ: 15
TOP: Respiratory Syncytial Virus (RSV)
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6
...
Fine crackles
b
...
Expiratory wheezing
d
...
The
expiratory wheeze is most pronounced
...
What is the best intervention for the nurse caring for a child experiencing an acute asthma attack?
a
...

b
...

c
...

d
...

ANS: D
This position is comfortable and allows maximum use of the accessory muscles for breathing
...
Carbonated beverages are contraindicated in persons with dyspnea
...
What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale
Cromolyn?
a
...
At the initial onset of the attack
c
...
As often as 4 times a day
ANS: A
Anti-inflammatory inhalants are taken before exercise to prevent attacks
...
They are meant to be used as prophylactic therapies
...
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
...
Only one parent carries the CF gene
...
Both parents are carriers of the CF gene
...
The inheritance pattern is multifactorial
...
The result is probably a genetic mutation
...
Both parents must be carriers of the CF gene for the child to have the
disease
...
Which statement indicates that the childs parents understand how to perform respiratory therapy?
a
...

b
...

c
...

d
...

ANS: C
Postural drainage for the child with CF is done following nebulization
...

DIF: Cognitive Level: Analysis REF: Page 599 OBJ: 14
TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11
...
Pancreatic enzymes
b
...
Fat-soluble vitamins
d
...

DIF: Cognitive Level: Knowledge REF: Page 599 OBJ: 14
TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12
...
Clear the nasal passages after the infant has a feeding
...
Use over-the-counter nose drops to clear passages
...
Remove nasal secretions with a bulb syringe
...
Instill saline nose drops after clearing away secretions
...


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DIF: Cognitive Level: Application REF: Page 580 OBJ: 2
TOP: Nasopharyngitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
13
...
Which fluids are most appropriate?
a
...
Carbonated beverages
c
...
Cold milk
ANS: A
Room temperature fluids are the best
...
Milk stimulates mucus
production
...
The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is
sweating profusely
...
Severe asthma attack
b
...
Onset of bronchitis
d
...

DIF: Cognitive Level: Analysis REF: Page 591, Table 25-2
OBJ: 11 TOP: Asthma KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
15
...
What
significant information would the nurse include?
a
...
Positioning the infant prone for sleep
c
...
Placing infants on their backs or sides for sleep
ANS: D
The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying
position on a firm mattress to prevent SIDS
...
An infant is hospitalized with RSV bronchiolitis
...
Fatigue related to increased work of breathing
b
...
Risk for fluid volume deficit related to tachypnea and decreased oral intake
d
...

DIF: Cognitive Level: Analysis REF: Page 583-584
OBJ: 5 TOP: Respiratory Syncytial Virus (RSV)

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KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Physiological Integrity
17
...
Which assessment finding would
indicate the child is experiencing increased respiratory obstruction?
a
...
Tachycardia
c
...
Expiratory wheezing
ANS: A
Restlessness is a primary sign of increased respiratory obstruction
...
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
...
Discoloration of tooth enamel
b
...
Irritation of oral membranes
d
...

DIF: Cognitive Level: Comprehension REF: Page 593 OBJ: 12
TOP: Candidiasis KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological therapies
19
...
How long is this patient at the
highest risk for pulmonary edema after exposure?
a
...
4 hours
c
...
72 hours
ANS: D
Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure
...
Which is the most appropriate nursing action when planning care for a child with cystic fibrosis?
a
...

b
...

c
...

d
...

ANS: D
The maintenance of adequate nutrition is essential
...
Chest
physiotherapy should be done between meals
...
Children with cystic fibrosis should be weighed daily
...
The first child of a couple is being treated for bronchopulmonary dysplasia (BPD)
...
What will the nurse explain as the best
way to prevent BPD?
a
...
Exercise
c
...
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
...
Respiratory distress in the
newborn is the major reason why oxygen and ventilators are used for prolonged periods
...
Therefore the prevention of preterm births is the best way to
prevent BPD
...
The nurse describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that
apply
...
Mouth breathing
b
...
Dark circles under the eyes
d
...
Reddened conjunctiva
ANS: A, B, C, E
The allergic salute does not include a productive cough
...
The nurse would suggest the parents of an asthmatic child to encourage participation in which sport(s)?
(Select all that apply
...
Swimming
b
...
Baseball
d
...
Distance running
ANS: A, B, C
Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics
...

DIF: Cognitive Level: Comprehension REF: Page 593 OBJ: 11
TOP: Sports Activities Suitable for Asthmatics
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
24
...
)
a
...
Vomiting
c
...
Jaundice
e
...

DIF: Cognitive Level: Comprehension REF: Page 587 OBJ: 1
TOP: Meconium Ileus KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25
...
)
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
...

DIF: Cognitive Level: Comprehension REF: Page 593 OBJ: 12
TOP: Pursed-Lip Breathing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26
...
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
...
In pediatrics, bed rest means providing
play therapy that promotes minimal activity
...

DIF: Cognitive Level: Application REF: Page 579 OBJ: 3
TOP: Bed Rest KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
27
...
Which symptoms might lead the nurse to this
suspicion? (Select all that apply
...
Child reports tooth pain
...
Severe wheezing is auscultated on inspiration
...
Child reports, I have had a cold for 2 weeks
...
Nurse observes periorbital swelling
...
Halitosis is present
...
The
maxillary and ethmoid sinuses are most often involved in childhood sinusitis
...
An acute sinusitis is suspected when an upper respiratory infection lasts longer
than 10 days, with a daytime cough
...
Untreated sinusitis can lead to periorbital
cellulitis
...


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DIF: Cognitive Level: Comprehension REF: Page 581 OBJ: 4
TOP: Sinusitis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28
...
influenzae type B
...
)
a
...
Restlessness
c
...
Child insists on lying down
e
...
influenzae type B and most often occurs in children 3 to 6 years of age
...
The
course is rapid and progressive
...
The child insists on sitting up, leans forward with the mouth open, and drools saliva because of the
difficulty in swallowing
...
Cough is absent
...
However, the examining tongue blade may trigger a
laryngospasm and result in sudden respiratory arrest
...
What will the nurse discourage when providing education to parents of a child with asthma? (Select all that
apply
...
Stuffed toys
b
...
Gymnastics
d
...
Cotton blankets
ANS: A, D
Use of stuffed toys is discouraged due to potential allergens
...
Certain pets are encouraged, gymnasitics is usually well tolerated, and cotton
blankets are recommended for children with asthma
...
The nurse explains that the ____________________ can sense the oxygen concentration in the blood and
signal the brainstem to increase respiration
...

DIF: Cognitive Level: Knowledge REF: Page 578 OBJ: 2
TOP: Chemoreceptors KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31
...


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ANS:
9
After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral
medications affect the integrity of the immunizations
...
The nurse reviews Accolate and Zyflo, which are _______________ _______________; they are capable
of blocking the inflammatory response as well as providing bronchodilation
...

DIF: Cognitive Level: Knowledge REF: Page 591, Table 25-2
OBJ: 12 TOP: Leukotriene Modifiers
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33
...
Put a comma and space
between each answer choice (a, b, c, d, etc
...
Bronchopneumonia
b
...
Pulmonary edema
ANS:
B, C, A
Smoke inhalation injury may cause carbon monoxide poisoning
...
There are three stages of inhalation injury:
1
...
Pulmonary edema from 6 to 72 hours
3
...
What does the nurse explain that a ventricular septal defect will allow?
a
...
Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
c
...
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
...
This particular shift does not cause cyanosis
...
Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?
a
...
Cyanosis when crying
c
...
A machinery-like murmur
ANS: A
A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect
...
What finding would the nurse expect when measuring blood pressure on all four extremities of a child with
coarctation of the aorta?
a
...
Blood pressure higher on the left side
c
...
Blood pressure lower in the legs than in the arms
ANS: D
The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses
between the upper and lower extremities
...

DIF: Cognitive Level: Comprehension REF: Page 609 OBJ: 4
TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4
...
What is the nurses
best response?
a
...

b
...

c
...

d
...

ANS: A
The squatting position allows the child to breathe more easily because systemic venous return is increased
...
An infant is experiencing dyspnea related to patent ductus arteriosus (PDA)
...
Blood is circulated through the lungs again, causing pulmonary circulatory congestion
...
Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia
...
Blood is shunted past cardiac arteries, causing myocardial hypoxia
...
Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the
heart
...

DIF: Cognitive Level: Comprehension REF: Page 608-609
OBJ: 4 TOP: Congenital Heart Disease
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6
...
Counting the apical rate for 30 seconds before administering the medication
b
...
Repeating a dose if the child vomits within 30 minutes of the previous dose
d
...

DIF: Cognitive Level: Application REF: Page 612 OBJ: 5
TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7
...
Which areas of the heart are affected by carditis?
a
...
Heart muscle and the mitral valve
c
...
Contractility of the ventricles
ANS: B
The tissues that cover the heart and heart valves are affected
...

DIF: Cognitive Level: Knowledge REF: Page 614 OBJ: 6
TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8
...
He is always hungry
...
He tires out during feedings
...
He is fussy for several hours every day
...
He sleeps all the time
...

DIF: Cognitive Level: Application REF: Page 611-612
OBJ: 3 TOP: Congenital Heart Disease
KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9
...
The childs parent asks the nurse, How
does Kawasaki disease affect my childs heart and blood vessels? On what understanding is the nurses response
based?
a
...

b
...

c
...

d
...

ANS: A
Inflammation of vessels weakens the walls of the vessels and often results in aneurysm
...
The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes
cyanotic
...
If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest
...
If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body
...
If the baby turns blue, I will immediately put the baby upright in an infant seat
...
If the baby turns blue, I will put the baby in supine position with his head elevated
...

DIF: Cognitive Level: Application REF: Page 610, Figure 26-3
OBJ: 4 TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
11
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 609-610
OBJ: 4 TOP: Tetralogy of Fallot
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12
...
Which combination of symptoms, in conjunction
with this finding, would confirm a diagnosis of rheumatic fever?
a
...
Painful, tender joints and carditis
c
...
Chorea and elevated sedimentation rate
ANS: B
The presence of two major Jones criteria would indicate a high probability of rheumatic fever
...
An infant with congestive heart failure is receiving digoxin (Lanoxin)
...
Restlessness
b
...
Increased urinary output
d
...

DIF: Cognitive Level: Comprehension REF: Page 612 OBJ: 5
TOP: Heart Failure KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
14
...
The patent ductus arteriosus
b
...
The closure of the foramen ovale
d
...

DIF: Cognitive Level: Knowledge REF: Page 610 OBJ: 3
TOP: Hypoplastic Left Heart Syndrome KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15
...
What does the nurse
recognize that this indicates?
a
...
Hypoxia
c
...
Decreasing level of consciousness
ANS: C
As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenhams chorea,
manifested by involuntary, purposeless movements of the limbs
...
How long should a 4-year-old child recovering from rheumatic fever need to receive monthly injections of
penicillin G?
a
...
2 years
c
...
10 years
ANS: C
Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G
injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to prevent further
bouts of rheumatic fever
...
What is accurate about the characteristics of high-density lipoproteins (HDLs)?
a
...

b
...

c
...

d
...

ANS: C
HDLs have low amounts of triglycerides, large amounts of proteins, low amount of cholesterol, and are
excreted via the liver
...

DIF: Cognitive Level: Knowledge REF: Page 616 OBJ: 11
TOP: High-Density Lipoproteins KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18
...
A fat intake reduction of 5-10% of total calories
b
...
A fat intake reduction of 15-20% of total calories
d
...

DIF: Cognitive Level: Knowledge REF: Page 616 OBJ: 11
TOP: Heart-Healthy Diet KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19
...
What should be the main focus of the nurse
when presenting information?
a
...
Surgical interventions available
c
...
Reduction of aerobic exercise
ANS: C
The main focus of a hypertension-prevention program is patient education
...
A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is structurally normal
and to localize a murmur
...
Barium swallow
b
...
Electrocardiogram
d
...

DIF: Cognitive Level: Knowledge REF: Page 607, Table 26-7

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OBJ: N/A TOP: Diagnostic Tests
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
MULTIPLE RESPONSE
21
...
)
a
...
Using a soft nipple with enlarged holes
c
...
Substituting glucose water for formula
e
...
Feeding can be given more frequently in smaller amounts through a soft,
large-holed nipple
...
The child may be encouraged to
nurse if he or she is held
...
What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select the four that
apply
...
Hypertrophied right ventricle
b
...
Ventral septal defect
d
...
Dextroposition of aorta
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
...
What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a
paroxysmal hypercyanotic episode? (Select all that apply
...
Spontaneous cyanosis
b
...
Weakness
d
...
Syncope
ANS: A, B, C, E
Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea,
weakness, and syncope
...
Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply
...
Atrial septal defects (ASDs)
b
...
Dextroposition of aorta

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d
...
Ventricular septal defects (VSDs)
ANS: A, D, E
The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus
arteriosus
...
A 16-year-old patient is diagnosed with primary hypertension
...
)
a
...
Stress
c
...
Obesity
e
...
Nevertheless, heredity,
obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension
...
The nurse takes into consideration that the most common congenital heart defect is the ____________
____________ defect
...

DIF: Cognitive Level: Knowledge REF: Page 615 OBJ: 2
TOP: VSD KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27
...

ANS:
pulse pressure
The pulse pressure is the difference between the diastolic pressure and the systolic pressure
...
Because the diagnosis of rheumatic fever is difficult, an aid used to identify the presence of rheumatic fever
is the _____________ _______________
...
The

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245

formula for making the diagnosis of rheumatic fever is to identify two major criteria in the patient, or one
major and two minor criteria
...
________________________is designed to serve the metabolic needs during intrauterine life and also to
permit safe transition to life outside the womb
...

DIF: Cognitive Level: Knowledge REF: Page 614 OBJ: 2
TOP: Fetal Circulation KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
30
...

ANS:
height; weight
Systemic blood pressure increases with age and is correlated with height and weight throughout childhood and
adolescence
...

DIF: Cognitive Level: Knowledge REF: Page 615 OBJ: 8
TOP: Hypertension KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention
31
...
It belongs to a group of disorders known as collagen diseases
...
It belongs to a group of disorders known as collagen diseases
DIF: Cognitive Level: Knowledge REF: Page 613 OBJ: 1
TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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Chapter 27: The Child with a Condition of the Blood, Blood-Forming
Organs, or Lymphatic System
MULTIPLE CHOICE
1
...
What food
would the nurse emphasize as being a rich source of iron?
a
...
Cream of Wheat
c
...
A carrot
ANS: B
Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried
fruits, beans, nuts, and whole-grain breads
...
Which statement by a mother may indicate a cause for her 9-month-olds iron deficiency anemia?
a
...
We switched to regular milk right away
...
She almost never drinks water
...
She doesnt really like peaches or pears, so we stick to bananas for fruit
...
I give her a piece of bread now and then
...

ANS: A
Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life
...
What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric
unit?
a
...
With orange juice
c
...
On a full stomach
ANS: B
Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron
...
What is the result of a deficiency of factor IX?
a
...
Idiopathic thrombocytopenic purpura
c
...
Christmas disease
ANS: D
Christmas disease, or hemophilia B, is caused by the deficiency of factor IX
...
A 2-year-old child has been diagnosed with hemophilia A
...
If bleeding occurs, apply pressure, ice, elevate, and rest the extremity
...
Childrens 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
...

DIF: Cognitive Level: Application REF: Page 628 OBJ: 12
TOP: Hemophilia KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6
...
Ibuprofen
b
...
Caffeine
d
...

DIF: Cognitive Level: Application REF: Page 629 OBJ: N/A
TOP: Leukemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7
...
Fever
b
...
Jaundice
d
...

DIF: Cognitive Level: Comprehension REF: Page 632-633
OBJ: 16 TOP: Blood Transfusion
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
8
...
What is
the priority nursing intervention?
a
...
Inserting an intravenous line
c
...
Providing family education about how to prevent bleeding
ANS: A
When platelets are low, the greatest danger is spontaneous intracranial bleeding
...

DIF: Cognitive Level: Application REF: Page 629 OBJ: 15
TOP: Leukemia KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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9
...
Lymph nodes on both sides of her diaphragm have been
found to be involved, including cervical and inguinal nodes
...
I
b
...
III
d
...

DIF: Cognitive Level: Application REF: Page 633, Table 27-2
OBJ: N/A TOP: Hodgkins Disease
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
10
...
Which type of crisis is the child most likely experiencing?
a
...
Hyperhemolytic
c
...
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
...
Which statement made by a parent indicates an understanding of health maintenance of a child with sickle
cell disease?
a
...

b
...

c
...

d
...

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
...
A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait
...
Every fourth child will have the disease; two others will be carriers
...
All of their children will be carriers, just as they are
...
Each child has a one in four chance of having the disease and a two in four chance of being a carrier
...
The risk levels of their children cannot be determined by this information
...

DIF: Cognitive Level: Analysis REF: Page 625, Figure 27-4

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OBJ: 7 TOP: Sickle Cell Disease
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
13
...
What is a complication of repeated
blood transfusions?
a
...
Hematuria
c
...
Hemosiderosis
ANS: D
As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues
...
A child has just been diagnosed with acute lymphoblastic leukemia
...
Decreased T-cell production
b
...
Increased blood clotting
d
...

DIF: Cognitive Level: Comprehension REF: Page 630 OBJ: 14
TOP: Leukemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15
...
What is the best initial action by the
nurse?
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
...
What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy?
a
...

b
...

c
...

d
...

ANS: B
A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and
infection
...
Water-Pik is useful for
toughening gums
...
A 6-year-old with leukemia asks, Who will take care of me in heaven? What is the best response by the
nurse?
a
...
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?
ANS: A
This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed
responses shut off communication
...

DIF: Cognitive Level: Application REF: Page 632 OBJ: 18
TOP: Leukemia KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
18
...
What should the nurse
remember the childs concept of death is at this age?
a
...
Only a fear of separation from her parents
c
...
An understanding based on simple logic
ANS: C
The preschooler views death as reversible and temporary
...
The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his
extremities
...
Platelet count of 25,000/mm3
b
...
Hematocrit level of 36%
d
...
This finding is very low, indicating an increased
bleeding potential
...
The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly
distended
...
What do these assessment findings
suggest?
a
...
Stomatitis
c
...
Hemorrhage
ANS: A
Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the

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bowel
...
The nurse finds an adolescent with Hodgkins disease crying
...
What is
the most appropriate nursing response to this comment?
a
...

b
...

c
...
Tell me whats got you scared
...

DIF: Cognitive Level: Application REF: Page 638 OBJ: 18
TOP: Adolescent with CancerFear of Death
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22
...
What is
the priority nursing diagnosis for this child?
a
...
Risk for hemorrhage
c
...
Disturbance in body image
ANS: A
The child with neutropenia is at risk for infection
...
What important focus of nursing care for the dying child and the family should the nurse implement?
a
...

b
...

c
...

d
...

ANS: C
Hearing is intact even when there is a loss of consciousness
...
The nurse is presenting information on the congentital disorder of hemophilia A
...
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
...

The defective gene is on the X chromosome
...
A child is diagnosed with iron deficiency anemia
...
Hemorrhage
b
...
Infection
d
...
If this happens, heart failure follows
...
The nurse is caring for a child with a low platelet count
...
)
a
...
Purpura
c
...
Hematoma
e
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 629 OBJ: 13
TOP: Manifestations of Bleeding KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
27
...
)
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
...

DIF: Cognitive Level: Comprehension REF: Page 637-638
OBJ: 21 | 25 TOP: Siblings KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28
...
)
a
...
Appetite stimulation
c
...
Provision for expressions of anger
e
...
Low energy levels produce anorexia and
anger in many young patients
...

DIF: Cognitive Level: Application REF: Page 633 OBJ: N/A
TOP: Effects of Radiation KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
29
...
)
a
...
Jaundice
c
...
Pathological fractures
e
...

DIF: Cognitive Level: Comprehension REF: Page 627 OBJ: 10
TOP: Thalassemia Major KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
30
...
)
a
...
Can be administered by family at home
c
...
Reduces cost of care of the hemophiliac
e
...
Because it supplies the missing factor, transfusions are not
necessary and consequently the exposure to HIV and hepatitis A and B is reduced
...
The drug does not prevent
hemorrhage; it makes hemorrhage manageable
...
The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of
the childs care? (Select all that apply
...
Using a support group
b
...
Maintaining adequate hydration
d
...
Reporting exposure to infectious diseases
ANS: A, B, C, E
Support groups are helpful for emotional support and realistic tips on care
...
Maintenance of hydration is essential for the adequate therapeutic effect of the
drugs
...


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DIF: Cognitive Level: Analysis REF: Page 632 | Page 634-635, Nursing Care Plan 27-2
OBJ: 15 | 21 TOP: Chemotherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
32
...
)
a
...
Cyclophosphamide
c
...
Prednisone
e
...

DIF: Cognitive Level: Knowledge REF: Page 633 OBJ: N/A
TOP: COPP KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33
...
How would the nurse anticipate chronic
illness will effect growth and development? (Select all that apply
...
Delayed bonding with parents
b
...
Impaired sense of belonging
d
...
Impaired speech development
ANS: C, D
A school-age child is in the stage of industry versus inferiority
...

Sense of independence and accomplishment can be lost
...

DIF: Cognitive Level: Comprehension REF: Page 636 OBJ: 17
TOP: Chronic Illness/Growth and Development
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Grief and Loss
COMPLETION
34
...

ANS:
hemoglobin S
Hemoglobin S is the abnormal hemoglobin that makes red blood cells fragile and causes the walls of the cells
to collapse, giving them the characteristic sickle shape
...
The nurse confirms that sickle cell trait can be distinguished from sickle cell disease by a lab test called
________________
...

Hemoglobin is the substance in red blood cells that carries oxygen
...
Hemoglobin types have different electrical
charges and move at different speeds
...
An
abnormal amount of normal hemoglobin or an abnormal type of hemoglobin in the blood may mean that a
disease is present
...

DIF: Cognitive Level: Knowledge REF: Page 624 OBJ: 3
TOP: Electrophoresis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36
...

ANS:
cardiac arrhythmias
Cold blood entering the heart via a central line can trigger an irregular heartbeat
...
The rate of RBC production is regulated by _________________
...

DIF: Cognitive Level: Knowledge REF: Page 620 OBJ: 1 | 2
TOP: Components of Blood KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
38
...
Put a comma and space
between each answer choice (a, b, c, d, etc
...
Bargaining
b
...
Denial
d
...
Reaching out to help others
f
...
(Nurses may also
respond with similar feelings
...

DIF: Cognitive Level: Comprehension REF: Page 638 OBJ: 20
TOP: Stages of Dying KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: End of Life Concepts

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Chapter 28: The Child with a Gastrointestinal Condition
MULTIPLE CHOICE
1
...
Failure to pass meconium in 24 hours
b
...
Palpable mass in the sternal area
d
...

DIF: Cognitive Level: Comprehension REF: Page 644 OBJ: 2
TOP: Esophageal Atresia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2
...
What acid-base
imbalance would the nurse expect to occur from this persistent vomiting?
a
...
Hypernatremia
c
...
Alkalosis
ANS: D
Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting
...

DIF: Cognitive Level: Comprehension REF: Page 650-651 | Page 658, Table 28-5
OBJ: 9 TOP: Acid-Base Balance
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3
...
Which assessment finding indicates ineffectiveness of treatment?
a
...
Dry mucous membranes
c
...
Depressed fontanelle
ANS: A
Weight loss is the most significant indicator of dehydration because an infants weight comprises 77% water
...
Why are rapid respirations a possible cause of dehydration?
a
...

b
...

c
...

d
...

ANS: C
Rapid respirations cause increased insensible fluid loss
...
Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux?
a
...

b
...

c
...

d
...

ANS: A
After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure
...
The nurse is interviewing parents of an infant with pyloric stenosis
...
Diarrhea
b
...
Poor appetite
d
...
Food is ejected with considerable force, which is
described as projectile vomiting
...
A mother reports that her child has been scratching the anal area and complaining of itching
...
Pinworms
b
...
Ringworm
d
...
The other choices do not cause this reaction
...
The nurse is teaching a parent about pyrvinium (Povan)
...
Diarrhea
b
...
Red stool
d
...

DIF: Cognitive Level: Knowledge REF: Page 662 OBJ: 12
TOP: Worms KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

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9
...
Keep childrens nails short
...
Dress child in loose-fitting underwear
...
Clean the bathroom with bleach solution
...
Wash bed linens in cold water
...
Pinworms
are not spread from person to person
...
A mother reports that her 2-year-old child experiences constipation frequently
...
Cooked vegetables
b
...
Whole-grain cereal
d
...

DIF: Cognitive Level: Comprehension REF: Page 654 OBJ: N/A
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11
...
Currant jelly
b
...
Green liquid
d
...

DIF: Cognitive Level: Comprehension REF: Page 649 OBJ: 6
TOP: Intussusception KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
12
...
A barium enema
b
...
IV fluids until the spasms subside
d
...
Surgery is scheduled only if reduction is not achieved
...
Parents ask the nurse how their infant developed a Meckels diverticulum
...
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
...

DIF: Cognitive Level: Knowledge REF: Page 649 OBJ: 2
TOP: Meckels Diverticulum KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14
...
For what is this child at the highest
risk?
a
...
Hypocalcemia
c
...
Shock
ANS: D
Shock is the greatest threat to life in isotonic dehydration
...
A child is brought to the emergency department because he ingested an unknown quantity of
acetaminophen (Tylenol)
...
Activated charcoal
b
...
Vitamin K
d
...

DIF: Cognitive Level: Comprehension REF: Page 663 OBJ: 14
TOP: Acetaminophen Poisoning KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
16
...
What will be included
regarding primary sources of lead in the community?
a
...
Use of aluminum cookware
c
...
Inhaling smog
ANS: C
The primary source of lead is paint from old, deteriorating buildings
...
A frightened mother calls the pediatricians office because her child swallowed dishwashing detergent
...
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
...
The child should be
taken immediately to the nearest emergency department along with the packaging of the ingested substance
...
A child has been diagnosed with ascariasis (roundworm)
...
Ive 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
...

DIF: Cognitive Level: Comprehension REF: Page 662 OBJ: 12
TOP: Worms KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
19
...
Ribbon like
b
...
Bulky, frothy
d
...
Stools that are large, bulky, and frothy may indicate malabsorption
...
The nurse has reviewed dietary restrictions for celiac disease with concerned parents
...
Wheat
b
...
Barley
d
...
These children will have a
lifelong restriction of wheat, oats, barley, and rye
...
A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis
...
Prevent fluid and electrolyte imbalance
...
Prevent nutritional deficiency
...
Prevent skin breakdown
...
Prevent malabsorption
...

DIF: Cognitive Level: Application REF: Page 650 OBJ: N/A
TOP: Gastroenteritis KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22
...
What dietary modification
would the nurse advise?
a
...
Small amounts of clear fluids such as gelatin
c
...
Chicken soup because it is high in sodium
ANS: C
An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel
movements
...
What would the nurse expect to find in a child admitted to the hospital for nonorganic failure to thrive?
a
...
Be limp like a rag doll
c
...
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
...
Which nursing interventions will be implemented for the mother of a 10-month-old infant with nonorganic
failure to thrive?
a
...
Discussing negative characteristics of the infant with the mother
c
...
Teaching the mother about the developmental milestones to expect in the next few months
ANS: D
The nurse can increase parents knowledge of growth and development by providing anticipatory guidance
about normal developmental milestones
...
Which statement by a mother may indicate a cause of her sons vitamin C deficiency?
a
...

b
...

c
...

d
...

ANS: A
Vitamin C is destroyed by heat
...
The nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush
...
Pour the prescribed amount into a nipple and have the infant suck the medication
...
Squirt the prescribed dose into the back of the mouth and have the infant swallow
...
Give the medication mixed with a small amount of juice in a bottle
...
Use a sterile applicator to swab the medication on the oral mucosa
...

DIF: Cognitive Level: Application REF: Page 661 OBJ: 11
TOP: Thrush KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
27
...
They have a smaller surface area than adults in proportion to body weight
...
Water needs and losses per kilogram are lower than those for adults
...
A greater percentage of body water in infants is extracellular
...
Infants have a lower metabolic turnover of water
...

DIF: Cognitive Level: Knowledge REF: Page 656 OBJ: 8
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28
...
Laboratory results show pH 7
...
How does the nurse interpret these values?
a
...
Metabolic alkalosis
c
...
Respiratory alkalosis
ANS: A
A pH lower than 7
...
If the childs pH falls in the same line as the HCO3, the problem is
metabolic (see Table 27-4)
...
Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying
...
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
...
Feedings are gradually increased
to larger amounts of regular formula
...
The nurse is caring for an 18-pound child who has had one stool of diarrhea
...
18
b
...
64
d
...
18 pounds = 8
...

DIF: Cognitive Level: Analysis REF: Page 655 OBJ: 9
TOP: Oral Fluid Replacement KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
31
...
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
...
However, the American Academy of
Pediatrics (AAP) revised this policy in 2003
...
Ipecac syrup should not be kept in
the home
...

DIF: Cognitive Level: Comprehension REF: Page 663 OBJ: 13
TOP: Poison Control KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
32
...
2-month-old with a urine output of 150 mL in 24 hours
b
...
8-year-old with a urine output of over 1000 mL in 24 hours
d
...

DIF: Cognitive Level: Application REF: Page 657 OBJ: 9
TOP: Dehydration KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Adaptation: Physiological Integrity
MULTIPLE RESPONSE
33
...
)
a
...

b
...

c
...

d
...

e
...


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ANS: B, C, D
Children with pyloric stenosis are given formula thickened with cereal; the infant is burped before and during
feeding to get rid of any gas in the stomach; the infant is fed slowly and refed if vomiting occurs
...

DIF: Cognitive Level: Application REF: Page 645 OBJ: 3
TOP: Pyloric Stenosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34
...
)
a
...
Fever
c
...
Vomiting
e
...

DIF: Cognitive Level: Comprehension REF: Page 648 OBJ: 5
TOP: Hirschsprungs Disease KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
35
...
)
a
...
Dry mucous membranes
c
...
Increased urinary output
e
...

DIF: Cognitive Level: Comprehension REF: Page 657, Table 28-4
OBJ: 9 TOP: Moderate Dehydration
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
36
...
What signs and symptoms does the nurse
expect to assess? (Select all that apply
...
Left lower quandrant pain
b
...
Rebound tenderness
d
...
Pain on lifting thigh when supine
ANS: B, C, E
With appendicitis on examination, characteristic tenderness in the right lower quadrant known as McBurneys
point will occur
...
C-reactive protein
levels will be increased after 12 hours if any infection is present
...
Parents have adopted a child with the diagnosis of kwashiorkor
...
)
a
...
White streak in hair
c
...
Slowed growth
e
...
Oral
intake then is deficient in protein
...
The muscles become weak and wasted
...
Diarrhea, skin infections, irritability, anorexia,
and vomiting may be present
...
Because protein is the basis of melanin, a
substance that provides color to hair, melanin becomes deficient
...
The child looks apathetic and
weak
...
The nurse, assessing an elevated erythrocyte sedimentation rate (ESR) for an infant with gastroenteritis,
recognizes that this confirms the _______________ process that is part of this disease
...

DIF: Cognitive Level: Comprehension REF: Page 650 OBJ: 9
TOP: Gastroenteritis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
39
...

ANS:
caffeinated
Cola or other caffeinated drinks cause diuresis and will further dehydrate an already dehydrated child
...
The nurse explains that rickets, a deficiency disease that causes bony deformities, is caused by the
inadequate supply of vitamin ______
...

DIF: Cognitive Level: Knowledge REF: Page 660 OBJ: N/A
TOP: Rickets KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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41
...

ANS:
casein
Food labels that list casein contain cows milk
...
The nurse explains the medically accepted definition of constipation is fewer than _____ bowel movements
in a 2-week period
...

DIF: Cognitive Level: Knowledge REF: Page 654 OBJ: N/A
TOP: Constipation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
43
...

ANS:
herniorrhaphy
Hernias are successfully repaired by the surgical operation called a herniorrhaphy
...
Most children are scheduled for procedures in same-day surgery
units
...

DIF: Cognitive Level: Knowledge REF: Page 650 OBJ: 1
TOP: Hernias KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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Chapter 29: The Child with a Genitourinary Condition
MULTIPLE CHOICE
1
...

Which statement made by the parent indicates a need for further teaching?
a
...

b
...

c
...

d
...

ANS: C
Oils in bubble bath and similar products are known to irritate the urethra
...
When asked about correcting the hypospadias of a newborn, what does the nurse explain about this
condition?
a
...

b
...

c
...

d
...

ANS: B
Treatment of hypospadias consists of surgical repair and is usually performed before 18 months of age
...
What is an initial sign of nephrosis that the nurse might note in a child?
a
...
Periorbital edema
c
...
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
...
What is it important to assess in a child receiving prednisone to treat nephrotic syndrome?
a
...
Urinary retention
c
...
Hypoglycemia
ANS: A
Prednisone depresses the immune response and increases susceptibility to infection
...

DIF: Cognitive Level: Comprehension REF: Page 677 OBJ: 5
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Physiological Integrity
5
...

What action should the nurse implement?
a
...

b
...

c
...

d
...

ANS: C
Notify the charge nurse of this occurrence of paraphimosis
...

DIF: Cognitive Level: Application REF: Page 672 OBJ: 1
TOP: Paraphimosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
6
...
What is
the most appropriate nursing intervention for this child?
a
...
Feeding the child a protein-restricted diet
c
...
Observing the child for evidence of hypotension
ANS: A
Although children may feel well, activity is limited until hematuria resolves
...
Which urinary diversion procedure is the least damaging to the body image of the adolescent?
a
...
Ileal conduit
c
...
Suprapubic placement
ANS: B
The ileal conduit diverts urine to the colon, and the urine is excreted with the feces
...

DIF: Cognitive Level: Comprehension REF: Page 674, Table 29-2
OBJ: 10 TOP: Obstructive UropathyUrinary Diversions
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
8
...
What does the nurse clarify about receiving immunizations while on
prednisone?
a
...
Require that the child have antibiotic coverage
c
...
Should be delayed
ANS: D
No vaccinations or immunizations should be administered while the disease is active and during
immunosuppressive therapy
...
Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids
...
Ibuprofen, an anti-inflammatory agent
b
...
Ciprofloxacin (Cipro), an antibiotic
d
...

DIF: Cognitive Level: Application REF: Page 677 OBJ: 6
TOP: Nephrotic Syndrome KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
10
...
Dairy products
b
...
Organ meats
d
...

DIF: Cognitive Level: Comprehension REF: Page 678 OBJ: 6
TOP: AGN KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
11
...
Performing range-of-motion exercises on lower extremities
b
...
Assessing for bowel sounds
d
...

DIF: Cognitive Level: Application REF: Page 679, Safety Alert
OBJ: 8 TOP: Wilms Tumor
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12
...
Which statement by the
childs father causes the nurse to determine he understands the information presented?
a
...

b
...

c
...

d
...

ANS: A
Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only
one testis is undescended
...
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
...
Cystometrogram
b
...
Voiding cystourethrogram
d
...

DIF: Cognitive Level: Comprehension REF: Page 675 OBJ: 1
TOP: Diagnostic Procedures KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity
14
...
What does the nurse recognize
these signs and symptoms indicate?
a
...
Nephrotic syndrome
c
...
Vesicoureteral reflux
ANS: A
Urinary frequency and pain during micturition are symptoms of acute urinary tract infection
...
What is an appropriate intervention for the edematous child with reduced mobility related to nephrotic
syndrome?
a
...

b
...

c
...

d
...

ANS: B
The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate
skin
...
Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of
discharge teaching?
a
...

b
...

c
...

d
...

ANS: C
The parents should be instructed to keep a daily record of the childs urinary proteins
...
A 5-year-old boy is admitted to the hospital with acute glomerulonephritis
...
Recovery from German measles 2 months ago
b
...
A history of allergy
d
...

DIF: Cognitive Level: Comprehension REF: Page 677 OBJ: 7
TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
18
...
Which is the
best beverage for the nurse to recommend to keep urine acidic?
a
...
Grape juice
c
...
Orange juice
ANS: C
Juices such as apple or cranberry help maintain acidity of urine
...
The 6-year-old scheduled for an orchiopexy shyly asks the nurse, What are they going to do to me down
there? What is the nurses best response?
a
...

b
...

c
...
You shouldnt worry
...

ANS: C
Encourage the patient to talk about what he knows and what feelings he has about the surgery
...

DIF: Cognitive Level: Application REF: Page 681 OBJ: 10
TOP: Orchiopexy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
20
...
Contact sports
b
...
Alcohol
d
...

DIF: Cognitive Level: Comprehension REF: Page 679 OBJ: 10
TOP: Postnephrectomy Instruction KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
21
...
What
is the nurses best response?
a
...

b
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 680 OBJ: 4
TOP: Hydrocele KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
22
...
What
information is accurate to include?
a
...

b
...

c
...

d
...

ANS: D
When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism
...
Because the testes are warmer in the abdomen than in the scrotum, the sperm cells
begin to deteriorate
...
Inguinal hernia often accompanies this
condition
...
An operation
called an orchiopexy may be performed
...
An adolescent male is admitted to the ED with severe acute scrotal pain
...
What diagnosis does the nurse expect?
a
...
Nephrosis
c
...
Phimosis
ANS: C
When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism
...

DIF: Cognitive Level: Comprehension REF: Page 681 OBJ: 1
TOP: Torsion KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
MULTIPLE RESPONSE
24
...
What is the nurse aware this lab value might indicate? (Select
all that apply
...
Dehydration
b
...
Need for steroid therapy
d
...
Pituitary malfunction
ANS: A, B, C
Increased BUN can indicate dehydration, renal disease, and/or need for steroid therapy
...
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
...
These infants are diapered loosely, if at all
...

DIF: Cognitive Level: Application REF: Page 673 OBJ: 4
TOP: Exstrophy of the Bladder KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
26
...
)
a
...
Grossly bloody urine
c
...
Fatigue
e
...
The nephrotic
child has hypoalbuminemia, as most of the protein has been spilled in the urine
...
The nurse is aware that genitourinary surgery is especially stressful for preschool children
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, B, C, D
All options, except fear of death, are especially stressful for preschool children undergoing genitourinary
surgery
...

DIF: Cognitive Level: Comprehension REF: Page 681 OBJ: 10
TOP: Topic: Impact of Surgery on Preschoolers
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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28
...
)
a
...
Hypertension
c
...
Alteration in nutrition
e
...

DIF: Cognitive Level: Comprehension REF: Page 677 OBJ: 8
TOP: Long-Term Prednisone Therapy KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
COMPLETION
29
...

ANS:
uroflowmeter
The device that specifically measures the dynamics of micturition is the uroflowmeter
...
The nurse uses a diagram to show how the _______________, the working unit of the kidney, filters and
regulates fluids
...
There are roughly 1
million nephrons in each kidney
...
When a childs ureter becomes completely obstructed from scarring, the nurse explains that urinary
diversion may be necessary to prevent the reflux back into the renal pelvis from causing
____________________
...

DIF: Cognitive Level: Comprehension REF: Page 673 OBJ: 1
TOP: Hydronephrosis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32
...

ANS:
urgency

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Urgency is the term that describes the strong urge to void, often despite the inability to do so
...
The nurse is measuring ouput on an infant on the pediatric unit
...

ANS:
30
Diapers may be weighed on a gram scale before application and after removal (1 g = 1 mL)
...
________________ is a narrowing of the preputial opening of the foreskin, which prevents the foreskin
from being retracted over the penis
...

DIF: Cognitive Level: Knowledge REF: Page 672 OBJ: 1
TOP: Phimosis KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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276

Chapter 30: The Child with a Skin Condition
MULTIPLE CHOICE
1
...
How is
infant skin different from adult skin?
a
...
Greater moisture
c
...
Greater absorption
ANS: D
The childs skin has a dramatically greater ability to absorb than does that of the adult
...
What risk is increased with children who have been diagnosed with infantile eczema?
a
...
Acne
c
...
Asthma
ANS: D
Some children with eczema also develop asthma and hay fevertype allergies
...
What is the appropriate technique for the application of a topical treatment for a child with eczema?
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
...

DIF: Cognitive Level: Knowledge REF: Page 690 OBJ: 5
TOP: Infantile Eczema KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity
4
...
What is the best nursing action?
a
...

b
...

c
...

d
...

ANS: A
A staphylococcal infection can spread readily from one infant to another
...

DIF: Cognitive Level: Application REF: Page 692 OBJ: 7
TOP: Staphylococcal Infection KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity

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5
...
What information can the nurse provide
to the mother to start eradication of the lice?
a
...

b
...

c
...

d
...

ANS: C
Combing a vinegar and water solution through the hair with a fine-tooth comb and then shampooing is an
initial step toward eradication
...
A group of football players is taking oral griseofulvin for tinea pedis
...
Citrus fruit and juice
b
...
Alcohol consumption
d
...

DIF: Cognitive Level: Comprehension REF: Page 693 OBJ: 8
TOP: Tinea Pedis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
7
...
Get a prescription for oral contraceptives
...
Increase the dose of the present medication
...
Limit intake of chocolate, cola, and peanuts
...
Increase exposure to sunlight
...
Accutane can cause birth defects, so
pregnancy should be prevented
...
A child had a burn, evidenced by pink skin and blistering
...
How
does the nurse classify this burn when documenting?
a
...
Second-degree superficial
c
...
Third-degree
ANS: B
A second-degree superficial burn appears blistered, moist, and pink or red
...

DIF: Cognitive Level: Analysis REF: Page 696, Table 30-2
OBJ: 9 TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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9
...
What is the best first action to take?
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
...
Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns?
a
...
Iodine
c
...
Sulfa
ANS: D
The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy
...
What would help the child with a serious burn meet nutritional needs during the subacute phase of
recovery?
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
...
Which statement made by a parent indicates an understanding of the topical application of medications for
a skin condition?
a
...

b
...

c
...

d
...

ANS: A
Absorption of topical medications is best when preparations are applied after a warm bath
...
On the first day following a severe burn, the bodys fluid reserves have left the circulating volume and
entered the interstitial space, causing massive edema
...
Increasing intracranial pressure
b
...
Eschar formation
d
...

DIF: Cognitive Level: Application REF: Page 700 OBJ: 9
TOP: Burns KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
14
...
They tell the
nurse that the mark appeared a few weeks after birth
...
A port wine nevus
b
...
Exanthem
d
...

DIF: Cognitive Level: Comprehension REF: Page 685, Figure 30-3
OBJ: 3 TOP: Congenital Lesions
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
15
...
The nurse observes tiny
pinhead-sized reddened papules on the infants neck and axilla
...
Sun exposure
b
...
Infection
d
...

DIF: Cognitive Level: Comprehension REF: Page 686 OBJ: 7
TOP: Skin Infections KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
16
...
Rub baby oil on the infants head at night and shampoo the hair the next morning
...
Use a brush with firm bristles to loosen the scales on the babys head several times a day
...
Wash the babys head every night with a dandruff-control shampoo
...
Lubricate the babys head every morning with a small amount of olive oil
...

DIF: Cognitive Level: Application REF: Page 687 OBJ: N/A
TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
17
...
Wool is the best fabric for the infants clothing
...
I should avoid laundry detergents with fragrances
...
I put cotton gloves on the infants hands
...
The infants fingernails are kept short
...
Wool is avoided because of its allergy potential
...
What will the nurse include when teaching about general skin care measures that could help prevent acne?
a
...
Washing the face with a cleansing product frequently
c
...
Eating a balanced diet and getting sufficient rest
ANS: D
General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent
exacerbations
...
The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet
...
Report this sign immediately
...
Place a warm towel over the extremities
...
Gently sponge with cool water
...
Medicate for pain
...

DIF: Cognitive Level: Application REF: Page 701 OBJ: 14
TOP: Frostbite KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
20
...
What is the nurses first
priority?
a
...

b
...

c
...

d
...

ANS: A
Airway assessment and establishing an airway are the initial priorities
...
An adolescent girl with acne is being treated with an antibiotic in addition to topical applications
...
Lessened effectiveness of oral contraceptives
b
...
Breast engorgement
d
...

DIF: Cognitive Level: Comprehension REF: Page 688 OBJ: 4
TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
22
...

Which complication does the nurse document and report?
a
...
Stress diarrhea
c
...
Perforated bowel
ANS: C
Curlings ulcer is a complication of burn victims resulting from the stress of their trauma
...
A child is brought to the emergency department with severe frostbite
...
Hands and arms
b
...
Fingers and toes
d
...

DIF: Cognitive Level: Application REF: Page 701 OBJ: 14
TOP: Frostbite KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
24
...
The itching is worse during the night and he has not been sleeping well
...
Scabies
b
...
Tinea corporis
d
...

DIF: Cognitive Level: Comprehension REF: Page 694 OBJ: 8
TOP: Scabies KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
25
...
The condition is caused by the herpes simplex virus type I
...
The crusts on the lesions should be left in place
...
The lesions may spread, but the disease is not contagious
...
Small cuts and bites should be treated promptly
...

The crusts from the lesions should be gently removed
...

DIF: Cognitive Level: Comprehension REF: Page 692 OBJ: 7
TOP: Impetigo KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
26
...
What is the nurse aware is the minimum adequate
hourly urine output?
a
...
10 mL/hr
c
...
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
...
An adolescent patient at a pediatric clinic presents with a butterfly rash
...
Tuberous sclerosis
b
...
Psoriasis
d
...

DIF: Cognitive Level: Comprehension REF: Page 686 OBJ: N/A
TOP: Skin Manifestations of Illness KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
28
...
What term can be used for an elevated, fluidfilled blister?
a
...
Papule
c
...
Vesicle
ANS: D
A vesicle is an elevated, fluid-filled blister (cold sore, chickenpox)
...
What should the nurse keep in mind when providing care to the school-age child hospitalized with a burn
injury?
a
...

b
...

c
...

d
...


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ANS: C
A burn injury is taxing to the child and parents
...
The accident itself is terrifying for the child but is made even worse if caused by disobedience
...
Analgesics are administered before painful procedures
...
School tutors are requested, and contact is
maintained with peers through cards or e-mail
...
Parents of a child show the nurse that their child has a flat strawberry nevus
...
)
a
...

b
...

c
...

d
...

e
...

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
...
At first it is flat, but it
gradually becomes raised
...
Laser treatment or excision may be considered if the area
becomes ulcerated
...
What would the nurse teach parents to do in order to avoid diaper rash? (Select all that apply
...
Use ointments
...
Keep perineum covered at all times
...
Use disposable diapers
...
Avoid plastic bloomers or pants
...
Change diaper frequently
...

DIF: Cognitive Level: Comprehension REF: Page 687 OBJ: N/A
TOP: Avoiding Diaper Rash KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
32
...
)
a
...
Phenytoin
c
...
Aspirin
e
...

DIF: Cognitive Level: Knowledge REF: Page 688 OBJ: 7
TOP: Acne KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
33
...
)
a
...

b
...

c
...

d
...

e
...

ANS: B, C
Use of oatmeal, baking soda, and baking powder is soothing
...
Items with any fragrance should be avoided as
well as lanolin-based products
...

DIF: Cognitive Level: Comprehension REF: Page 690 OBJ: 5
TOP: Infantile Eczema KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
34
...
)
a
...
Sun
c
...
Fever
e
...
Food allergies do not activate the virus as a rule
...
The nurse recognizes the blisters and erythema of the hands of a person recovering from frostbite as the
skin disorder called _________________
...
These are called
chilblains
...
The nurse differentiates a type of topical medication that is an oil-based emulsion to be used on dry skin as
a(n) _________________
...


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285

DIF: Cognitive Level: Comprehension REF: Page 692, Table 30-1
OBJ: 6 TOP: Ointment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
37
...
The nurse assesses the body surface area
(BSA) percentage burn as ______%
...
5%, the hand = 2
...
Together this totals to 26% BSA burn
...
The nurse recognizes the characteristic circular hairless patches of tinea capitis, which is called
_____________
...

DIF: Cognitive Level: Knowledge REF: Page 693 OBJ: 1
TOP: Alopecia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
39
...

ANS:
full; 10
A full-thickness burn involving 10% or more of the body surface is considered a major burn
...
Eczema indicates that the infant is oversensitive to certain substances called ______________, which enter
the body via the digestive tract, inhalation, direct contact, or injections
...
It indicates that the infant is oversensitive to certain
substances called allergens, which enter the body via the digestive tract (food), by inhalation (dust, pollen), by
direct contact (wool, soap, strong sunlight), or by injections (insect bites, vaccines)
...
A nurse is planning to teach a family about Tay-Sachs disease
...
They are usually autosomal recessive
...
They are usually autosomal dominant
...
They are usually X-linked recessive
...
They are usually multifactorial
...

DIF: Cognitive Level: Knowledge REF: Page 704 OBJ: 2
TOP: Tay-Sachs KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2
...
Protein synthesis is increased
...
Increased fat breakdown leads to ketonemia
...
Serum glucose levels are markedly decreased
...
More rapid conversion and storage of carbohydrates to glucose occurs
...
The body is also unable to
store and use fat properly
...

DIF: Cognitive Level: Comprehension REF: Page 706 OBJ: 9
TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 707, Table 31-2
OBJ: 5 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4
...
At 8:45 AM the breakfast trays have
not yet arrived from the kitchen
...
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 snack of graham crackers and milk will prevent an episode of hypoglycemia
...
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
...
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
...
Giving more sugar will increase the
blood glucose in a hyperglycemic child
...
The treatment for
hyperglycemia is to give the patient more insulin
...
Which comment made by a school-age child indicates that he needs more teaching about diabetes mellitus
and exercise?
a
...

b
...

c
...

d
...

ANS: C
Blood glucose is high after meals
...

DIF: Cognitive Level: Comprehension REF: Page 711, Nursing Care Plan 31-1 | Page 712
OBJ: 9 TOP: Diabetes Mellitus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7
...
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
...
Insulin does not cure the pancreas
...
Which general dietary measure should the nurse include in a teaching plan for the child with type 1 diabetes
mellitus?
a
...

b
...

c
...

d
...


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288

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
...

DIF: Cognitive Level: Comprehension REF: Page 712 OBJ: 9
TOP: Diet KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9
...
He is flushed and drowsy, and his skin is dry
...
What is this child most
likely experiencing?
a
...
Dawn syndrome
c
...
Water intoxication
ANS: C
In ketoacidosis, the childs skin is dry, and the face is flushed
...
They may perspire
and be restless
...

DIF: Cognitive Level: Analysis REF: Page 709, Table 31-4
OBJ: 7 TOP: Ketoacidosis
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
The nurse
recognizes these signs are characteristic of what?
a
...
Hyperthyroidism
c
...
Tay-Sachs disease
ANS: A
The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy
respiration
...
What is an important consideration for the school-age child taking DDAVP for diabetes insipidus?
a
...

b
...

c
...

d
...

ANS: C
The child with diabetes insipidus needs liberal access to bathrooms and water fountains
...

DIF: Cognitive Level: Application REF: Page 705-706
OBJ: 4 TOP: Diabetes Insipidus
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
12
...
Glycosylated hemoglobin value of 8%
b
...
Glucose tolerance test result of 190 mg/dL
d
...
Levels of 6% to 9% represent good
metabolic control
...
What condition does the nurse suspect when a child with type 1 diabetes mellitus has hyperglycemia,
diaphoresis, and headaches in the morning?
a
...
Somogyi phenomenon
c
...
Ketoacidosis
ANS: B
The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the
point at which the bodys counter-regulatory hormones are released, producing the symptoms described
...
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
...
It is unlikely that you would have a child with Tay-Sachs disease
...
A screening test can be done to determine if you are a carrier of the gene
...
The gene for Tay-Sachs disease is transmitted by the father
...
The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus
...
Tay-Sachs disease has an autosomal recessive pattern of
transmission
...
What statement by a parent leads the nurse to determine a parent is administering levothyroxine
(Synthroid) correctly?
a
...

b
...

c
...

d
...

ANS: D
Synthroid should be given at the same time each day, preferably in the morning
...
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)
...
Diabetes insipidus
b
...
Hypothyroidism
d
...
The child can become dehydrated very
quickly if some remedy is not applied
...
The nurse is teaching the parents of a child with diabetes insipidus about water intoxication
...
Polyuria
b
...
Weight loss
d
...

DIF: Cognitive Level: Comprehension REF: Page 705-706
OBJ: 2 TOP: Diabetes Insipidus
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
18
...
With what does the nurse recognize this description is consistent?
a
...
Type 2, noninsulin-dependent diabetes mellitus
c
...
Drug-induced diabetes
ANS: B
Type 2, noninsulin-dependent diabetes mellitus is caused by insulin resistance or failure of the body to use the
insulin
...
What does the nurse instruct a 12-year-old to do when teaching how to administer insulin?
a
...

b
...

c
...

d
...

ANS: C
Children often find it easier to learn to inject the needle at a 90-degree angle
...
The nurse discussed treatment of hypoglycemia with an adolescent
...
When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers
...
When my blood glucose is low or if I begin to feel hungry and weak, I will give myself Lispro insulin
...
When my blood glucose is low or if I begin to feel hungry and weak, I will have a slice of cheese
...
When my blood glucose is low or if I begin to feel hungry and weak, I will drink a diet soda
...
Cheese will eventually raise the blood glucose, but not as quickly as
candy
...
Why does the nurse instruct an 11-year-old diabetic child to use the side of the finger for blood testing?
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
...

DIF: Cognitive Level: Comprehension REF: Page 710 OBJ: 9
TOP: Finger Stick KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
22
...
Releases insulin as blood glucose rises
b
...
Decreases need for painful glucose monitoring
d
...

DIF: Cognitive Level: Knowledge REF: Page 714 OBJ: 9
TOP: Insulin Pump KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
23
...
Which insulin is considered long acting?
a
...
Aspart
c
...
Regular
ANS: C
Insulin glargine is a long-acting insulin
...
Lispro and Aspart are rapid acting
...
When discussing possible causes of diabetes in children, the nurse mentions chromosomal defects
...
)

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292

a
...
7
c
...
20
e
...

DIF: Cognitive Level: Knowledge REF: Page 707 OBJ: N/A
TOP: Diabetes Mellitus KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
25
...
)
a
...
Cooked vegetables
c
...
Lean meat
e
...

DIF: Cognitive Level: Comprehension REF: Page 712 OBJ: 9
TOP: Dietary Fiber Sources KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
26
...
)
a
...
Serum cholesterol
c
...
Absorption of sugar
e
...
It has
no effect on infections
...
Which process(es) does the nurse explain the endocrine system is primarily responsible for controlling?
(Select all that apply
...
Maturation
b
...
Stress response
d
...
Growth
ANS: A, B, C, E
The endocrine system governs maturation, reproduction, stress response, and sexual maturity
...

DIF: Cognitive Level: Comprehension REF: Page 703 OBJ: 2
TOP: Endocrine System KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

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293

28
...
Which symptoms does the nurse recognize as signs of overdose? (Select all that apply
...
Tachycardia
b
...
Vomiting
d
...
Diaphoresis
ANS: A, B, E
All the options with the exception of weight gain and vomiting are indications of overdose of Synthroid
...

DIF: Cognitive Level: Comprehension REF: Page 706 OBJ: 3
TOP: Levothyroxine (Synthroid) Overdose
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
29
...
)
a
...
Developmental conflicts
c
...
Growth spurts
e
...
Medication schedules and diet restrictions do not correlate well with the
adolescents lifestyle of eating fast foods
...

DIF: Cognitive Level: Comprehension REF: Page 717, Table 31-7
OBJ: 8 TOP: Diabetic Adolescent
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
30
...
What signs and symptoms will alert
parents of the possibility of ketoacidosis? (Select all that apply
...
Chest congestion
b
...
Fruity breath
d
...
Nausea
ANS: C, E
Symptoms of ketoacidosis are compared with those of hypoglycemia
...
Lab values include ketonuria,
decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration
...
The nurse is discussing insulin shock with parents of a child recently diagnosed with diabetes mellitus
...
)
a
...

b
...

c
...

d
...

e
...


Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

294

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
...
The nurse reminds the parents of a diabetic with an insulin pump that the tubing of the pump should be
changed aseptically every ______ hours
...

DIF: Cognitive Level: Knowledge REF: Page 714 OBJ: 9
TOP: Insulin Pump KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
33
...

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
...
The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can evaluate average
glucose levels over a period of _____ to _____ months
...
An HbA1c
reading of 6% to 9% is normal; a reading of 12% or higher is indicative of DM
...
Long-acting types of insulin are seldom given to children because of the danger of ___________________
during sleep
...

DIF: Cognitive Level: Comprehension REF: Page 715 OBJ: 1 | 11
TOP: Insulin administration/Hypoglycemia
KEY: Nursing Process Step: Implementation

Test Bank - Introduction to Maternity and Pediatric Nursing 7e (Leifer 2015)

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

295

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296

Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural
Disasters and the Maternal-Child Patient
MULTIPLE CHOICE
1
...
Anticonvulsant
b
...
Antibiotic
d
...

DIF: Cognitive Level: Knowledge REF: Page 725 OBJ: 3
TOP: Effect of Steroids KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2
...
What is
the nurses best explanation?
a
...

b
...

c
...

d
...

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
...

DIF: Cognitive Level: Comprehension REF: Page 728, Table 32-1
OBJ: 4 TOP: Vaccines KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3
...
Macular
b
...
Vesicular
d
...

DIF: Cognitive Level: Knowledge REF: Page 727 OBJ: 2
TOP: Rashes KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4
...
Diarrhea
b
...
5 C (105 F) from the previous inoculation
c
...
Traveling to Europe in a week
ANS: B
A contraindication to giving the DTaP vaccine is a 40
...

DIF: Cognitive Level: Application REF: Page 731 OBJ: 6
TOP: Immunizations KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
5
...
Contact
b
...
Airborne infection
d
...

Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room
...
Which statement assures the nurse that parents understand how long a child who has varicella is contagious?
a
...

b
...

c
...

d
...

ANS: A
The child with varicella is contagious for 6 days after the appearance of the rash
...
Which statement made by a sexually active adolescent girl indicates an understanding of the prevention of
sexually transmitted diseases?
a
...

b
...

c
...

d
...

ANS: C
The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual
intercourse
...
What is the priority nursing diagnosis for a hospitalized infant who is HIV positive?
a
...
Altered nutrition
c
...
Risk for infection
ANS: D
The infant who is HIV positive has impaired immunologic functioning and is at high risk for infection
...
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 2 weeks after birth
c
...
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
...
A 10-year-old child is diagnosed with Hepatitis A
...
Came in contact with infected blood
b
...
Was bitten by a mosquito or a tick
d
...

DIF: Cognitive Level: Comprehension REF: Page 723, Health Promotion box
OBJ: 3 TOP: Hepatitis A KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
11
...
Which type of precautions would the nurse use when
caring for the infant?
a
...
Airborne-infection precautions
c
...
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
...
A 9-year-old child hospitalized for neutropenia is placed in protective isolation
...
Nurses and doctors wear gowns and masks because you have a condition that could be spread to others
...
The gown and mask are to protect you because you could get an infection very easily
...
Im wearing this because there are a lot of bacteria in the hospital
...
I might look scary but you wont need this after you have had medication for 24 hours
...


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299

DIF: Cognitive Level: Application REF: Page 727 OBJ: 3
TOP: Protective Isolation KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
13
...
Which vaccine would be contraindicated?
a
...
Inactivated polio vaccine
c
...
Hepatitis B
ANS: A
The influenza vaccine should not be given to children who are allergic to eggs
...
The nurse is preparing to administer immunizations at a well-child clinic
...
DTaP subcutaneously
b
...
Varicella intramuscularly
d
...

DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6
OBJ: 6 TOP: Hib KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
15
...
The nurse noted the rash was present on the trunk,
extremities, and face
...
With what is the nurse aware this type of rash is
consistent?
a
...
Roseola
c
...
Fifth disease
ANS: D
In fifth disease, the child has a generalized rash and the cheeks have a slapped-cheek appearance
...
What statement leads the nurse to determine that a childs parent understands information related to tick
bites?
a
...

b
...

c
...

d
...

ANS: D
People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites
...
An adolescent is taking tetracycline for a sexually transmitted disease
...
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
...

DIF: Cognitive Level: Comprehension REF: Page 740, Table 32-3
OBJ: 9 TOP: Sexually Transmitted Diseases
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18
...
What does this
mean?
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
...
Which is an example of an opportunistic infection?
a
...
Pneumocystis jiroveci
c
...
Smallpox
ANS: B
Pneumocystis jiroveci is the most common of opportunistic diseases
...
A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh
...
When explaining the chain
of infection, how does the nurse identify this laceration?
a
...
Portal of entry
c
...
Cector
ANS: B
The chain of infection refers to the way in which organisms spread and infect the individual
...
g
...
A portal of exit is the route by which
the organisms exit the body (e
...
, feces or urine)
...
g
...
A vector is an insect or animal that carries and spreads a disease
...
Why would a female adolescent with STDs resist reporting the condition? (Select all that apply
...
She is reluctant to name contacts
...
She is embarrassed
...
She doubts confidentiality
...
She doesnt want to take the medication
...
She dreads the pelvic examination
...
Adolescents doubt
the confidentiality of the agency and are reluctant to name contacts
...
What sources are examples of acquired immunity? (Select all that apply
...
Gamma globulin
b
...
Maternal antibodies
d
...
Immune globulin
ANS: B, D
Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination
...
Immune globulin is receiving the antibodies from some
other source, giving the person an immediate immunity but one that does not last
...
The well-child clinic nurse is preparing to give which immunizations to a healthy 2-month-old? (Select all
that apply
...
DTaP
b
...
IPV
d
...
PCV
ANS: A, B, C, E
All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR
...

DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6
OBJ: 6 TOP: Inoculations for a 2-Month-Old
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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24
...
What will the nurse instruct the family to
prepare in a disaster kit in case of emergency? (Select all that apply
...
Small television
b
...
Nonperishable food
d
...
Blankets
ANS: B, C, D, E
The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or manmade
disasters, such as bioterrorist attacks or bombings
...
A
battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential
...
The nurse is assisting with an admission assessment of a child with scarlet fever
...
)
a
...

b
...

c
...

d
...

e
...

ANS: A, C
A diagnosis of scarlet fever would indicate throat culture and assessment for desquamation
...
Droplet precautions would not be implemented for scarlet fever
...

DIF: Cognitive Level: Application REF: Page 724, Health Promotion box
OBJ: 2 TOP: Scarlet Fever
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
COMPLETION
26
...

ANS:
Mantoux
The Mantoux test is a screening test for the susceptibility to TB
...
An erythema and induration of more than 5 mm is considered a positive reading
...
The nurse uses a diagram showing how the wood tick acts as a(n) ______________ in the transmission of
Lyme disease
...


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DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 4
TOP: Vector KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28
...

ANS:
varicella (chickenpox)
Varicella has the distinctive sign of showing several types of skin lesions at the same time
...
A parent is concerned because her son was exposed to varicella at preschool
...

ANS:
14 to 21
The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days
...
The nurse demonstrates proper hand hygiene pointing out that the process should take a minimum of ____
seconds
...

DIF: Cognitive Level: Knowledge REF: Page 727, Nursing Tip
OBJ: 4 TOP: Hand Hygiene
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
31
...

ANS:
immune systems
The immune systems of children are not fully developed, which makes them a vulnerable population
...
A __________ is a worldwide high incidence of a communicable disease
...
_________________ refers to a continuous incidence
of a communicable disease expected in a localized area
...
An epidemic is a sudden increase of a
communicable disease in a localized area
...

DIF: Cognitive Level: Knowledge REF: Page 725 OBJ: 1
TOP: Key Terms KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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Chapter 33: The Child with an Emotional or Behavioral Condition
MULTIPLE CHOICE
1
...
Which is the nurses most helpful
response?
a
...

b
...

c
...

d
...

ANS: A
Learning disability is an educational term
...

DIF: Cognitive Level: Comprehension REF: Page 749 OBJ: N/A
TOP: Learning Disability KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2
...
You should focus your mind on positive thoughts
...
Everybody has a bad day now and then
...
Youre young
...
Tell me about the worst day of your life
...

DIF: Cognitive Level: Application REF: Page 754, Nursing Tip
OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
3
...
The adolescent is acting out and needs to be brought under control so the conference can continue
...
The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to
refocus
...
The adolescent is demonstrating that this problem requires the assistance of a psychiatrist
...
The adolescent is responding to the discrediting of his parents, which causes anxiety
...

DIF: Cognitive Level: Analysis REF: Page 757-758
OBJ: 10 TOP: Children of Alcoholics
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
4
...
Which statement would be
recognized as the greatest risk of suicide?
a
...

b
...
That should be enough time for the pills to work
...

c
...
So I think Ill use his gun
...

d
...
She told me to call because I was talking crazy about killing myself
...

DIF: Cognitive Level: Analysis REF: Page 752-753, NCP 33-1
OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
5
...
What would a
nurse assess as an early sign of depression in this boy?
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
...
A mother is concerned because her adolescent son is always in trouble for fighting at school and always
seems to be angry
...
Which understanding will guide the nurses
response?
a
...

b
...

c
...

d
...

ANS: D
Early recognition of and intervention for children of alcoholics are paramount
...

DIF: Cognitive Level: Comprehension REF: Page 757-758
OBJ: 10 TOP: Children of Alcoholics
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
7
...
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
...

DIF: Cognitive Level: Application REF: Page 750, Health Promotion Box
OBJ: 12 TOP: Attention Deficit Hyperactivity Disorder
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
8
...
Severely underweight

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b
...
Introverted perfectionist
d
...

DIF: Cognitive Level: Comprehension REF: Page 751-752
OBJ: 13 TOP: Bulimia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
9
...
For what does this disorder put the
adolescent at greater risk?
a
...
Depression
c
...
A learning disability
ANS: B
OCD is related to depression and other psychiatric disorders
...

DIF: Cognitive Level: Comprehension REF: Page 748-749
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
...
There really isnt anything to worry about
...
My daughter just doesnt have much of an appetite
...
She is just trying to punish me for divorcing her father
...
She seems to see herself as fat, even though her weight is below normal
...

DIF: Cognitive Level: Comprehension REF: Page 750, Figure 33-3
OBJ: 13 TOP: Anorexia Nervosa
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
11
...
Place the child in a location where she can watch all of the activity on the unit
...
Use the childs chronological age as a guide for communication
...
Keep the childs room free of toys or objects that she might want to take home with her
...
Organize care to provide as few disruptions to the routine as possible
...

DIF: Cognitive Level: Application REF: Page 748 OBJ: 4
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
12
...
What will the nurse
include?

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a
...

b
...

c
...

d
...

ANS: A
Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are
significant signs of dysfunction by 1 year of age
...
An adolescent is brought to the emergency department after an automobile accident
...
The nurse notes his speech is slurred and his gait is ataxic
...
Alcohol
b
...
Amphetamines
d
...

DIF: Cognitive Level: Analysis REF: Page 755, Table 33-1
OBJ: 8 TOP: Substance Abuse
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
14
...
For what does
the nurse recognize this as the street name?
a
...
Cocaine
c
...
Marijuana
ANS: C
Speed is the street name for methamphetamine
...
How would the nurse identify a member of the child guidance team who is a medical doctor with special
training in psychoanalytic theory?
a
...
Psychoanalyst
c
...
Counselor
ANS: A
The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist
...

DIF: Cognitive Level: Knowledge REF: Page 747 OBJ: 2
TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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16
...
What therapeutic intervention might the
nurse implement that allows children to act out their feelings?
a
...
Play therapy
c
...
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
...
The nurse explains that use of stimulants will decrease hyperactivity in the autistic child
...
Sedating the child
b
...
Causing hypotension
d
...

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 4
TOP: Autism KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
18
...
For
what should the nurse assess?
a
...
Severe vomiting
c
...
Elevation of temperature
ANS: A
Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and general sensorium
...
The pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate
...
Becomes hyperactive and ceases to read
b
...
Makes up a story rather than reading the text
d
...

DIF: Cognitive Level: Comprehension REF: Page 749 OBJ: N/A
TOP: Dyslexia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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20
...
Recreational drug used occasionally
b
...
Drug used to wean from stronger drugs
d
...

DIF: Cognitive Level: Knowledge REF: Page 754, Nursing Tip
OBJ: 8 TOP: Gateway Drugs
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
21
...
Alcohol
b
...
Cocaine
d
...

DIF: Cognitive Level: Comprehension REF: Page 755, Table 33-1
OBJ: 8 TOP: Opiate Use KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
22
...
Perfect child
b
...
Flight
d
...
The perfect child is the child who tries to earn love by never causing any trouble
...
The nurse working with children from dysfunctional families must be prepared to address what associated
problem(s)? (Select all that apply
...
Lack of trust
b
...
Exaggerated self-confidence
d
...
Depression
ANS: A, B, E
Children from dysfunctional families exhibit lack of trust, act out, and show signs of depression
...
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
b
...
Stuttering
d
...
Nonnutritive sucking
ANS: C, D, E
Stuttering, aggressive behavior, and finger or thumb sucking that appear suddenly with no previous history are
a clue to increased nervous tension in the young school-age child
...

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 3
TOP: Nervous Tension KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
25
...
)
a
...
Pediatrician
c
...
Dietitian
e
...
The dietitian is not usually on the treatment team
...
The school nurse cautions a group of parents about the prevalence of children who get high by inhaling
hydrocarbons and fluorocarbons
...
)
a
...
Chlorine
c
...
Copy machine toner
e
...

DIF: Cognitive Level: Knowledge REF: Page 755, Table 33-1
OBJ: 8 TOP: Inhaling Hydrocarbons
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
27
...
What characteristic(s) cause this
disorder? (Select all that apply
...
Discomfort relative to emerging sexuality
b
...
Pervasive high self-esteem
d
...
Inability to meet developmental needs

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ANS: A, B, D, E
All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa
...

DIF: Cognitive Level: Comprehension REF: Page 750 OBJ: 13
TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
28
...
Which assessment
finding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply
...
Amenorrhea
b
...
Oily skin
d
...
Lanugo on back
ANS: A, B, E
The primary symptom of anorexia nervosa is severe weight loss
...
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
...
A nurse is hired to work in a psychiatric facility on a unit specializing in obsessive compulsive disorders
(OCD)
...
)
a
...
Hoarding disorder
c
...
Body dysmorphic disorder
e
...

DIF: Cognitive Level: Knowledge REF: Page 749 OBJ: 5
TOP: Obsessive Compulsive Disorder KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
30
...
Which characteristics would the
nurse assess in this child? (Select all that apply
...
Social anxiety
b
...
Hyperactivity
d
...
Inattention
ANS: B, C, D, E
ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility
...
The nurse documents that every time the child is directed to discuss the relationship with her brother, she
complains of shortness of breath and begins to have asthma-like symptoms
...

ANS:
psychosomatic
A psychosomatic reaction is one in which a dysfunction of the body has an emotional or mental cause
...
The nurse assists with the intervention of ____________ therapy, which provides a physical and social
environment that is stable and therapeutic
...

DIF: Cognitive Level: Knowledge REF: Page 747 OBJ: 1
TOP: Milieu Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
33
...
Situations that disrupt family patterns can
have a lasting impact on the child
...

ANS:
dysfunctional
Early childhood experiences are critical to personality formation
...
Children who come from these dysfunctional families may experience any
of the following: failure to develop a sense of trust (in their caregivers and environment), excessive fears,
misdirected anger manifested as behavioral problems, depression, low self-esteem, lack of confidence, and
feelings of lack of control over themselves and their environment
...
Put the 5 steps of the SAFE-T program in the correct order
...
)
a
...
Document and follow up
c
...
Identify protective factors
e
...

DIF: Cognitive Level: Comprehension REF: Page 754 OBJ: 7
TOP: Suicide
KEY: Nursing Process Step: Data Collection | Nursing Process Step: Intervention | Nursing Process Step:
Evaluation MSC: NCLEX: Psychosocial Integrity: Crisis Intervention

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Chapter 34: Complementary and Alternative Therapies in Maternity and
Pediatric Nursing
MULTIPLE CHOICE
1
...
What type of therapy does this describe?
a
...
Acupressure
c
...
Ayurveda
ANS: B
Acupressure uses finger pressure and massage on the meridian sites
...
It has been useful for minor postpartum problems such as constipation
...
Which child should not receive massage therapy?
a
...
12-year-old with diabetes mellitus
c
...
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
...
A 12-year-old with rheumatoid arthritis finds aromatherapy helpful for relieving her joint discomfort
...
Lavender
b
...
Ginseng
d
...

DIF: Cognitive Level: Knowledge REF: Page 765, Nursing Tip
OBJ: 2 TOP: Alternative Health PracticesAromatherapy
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4
...
What is the most appropriate
essential oil for the nurse to recommend?
a
...
Wintergreen
c
...
Citrus
ANS: D
Citrus is one essential oil that has been shown to be useful during labor and delivery
...
A parent asks the nurse, What is guided imagery? Which statement is the most accurate response?
a
...

b
...

c
...

d
...

ANS: A
In guided imagery, by focusing on a specific image, stress reduction and improved performance can result
...
A woman taking St
...
What
instruction should the nurse provide?
a
...

b
...
Johns wort must be stopped prior to surgery, but she can continue the ginseng
...
The ginseng should be stopped 1 week before surgery
...
She should discontinue taking both herbs 2 weeks before surgery
...
Johns wort and ginseng can cause problems during surgery, and their use should be discontinued 2
weeks before surgery
...
Which herb can the nurse suggest to be used for discomforts associated with menopause, such as hot
flashes?
a
...
Echinacea
c
...
Black cohosh
ANS: D
Black cohosh diminishes hot flashes by reducing luteinizing hormone
...

DIF: Cognitive Level: Knowledge REF: Page 769, Table 34-4
OBJ: 12 TOP: Herbal Remedies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
8
...
Reflexology
b
...
Guided imagery
d
...


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DIF: Cognitive Level: Comprehension REF: Page 760 OBJ: 3 | 9
TOP: Guided Imagery KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
9
...
Complementary therapy must be administered by a medical doctor
...
Complementary therapy is administered with conventional therapy
...
Complementary therapy replaces conventional therapy
...
Complementary therapy is administered to a group of patients at the same time
...

DIF: Cognitive Level: Comprehension REF: Page 760 OBJ: 2
TOP: CAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10
...
How will the nurse explain the definition of
meridians?
a
...

b
...

c
...

d
...

ANS: B
Meridians are invisible pathways through which energy travels to effect acupuncture treatment
...
Which herbal remedy used by a patient taking warfarin should the nurse report to the physician?
a
...
Chamomile
c
...
Kava-kava
ANS: A
Angelica prolongs prothrombin time and will synergize the effect of the warfarin
...
What should the nurse remind a parent who is considering homeopathic remedies for treatment of her
childs asthma?
a
...
Can be taken with traditional Western medications
c
...
May contain mercury, alcohol, or arsenic
ANS: D
Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually
...
Caffeine drinks are to be avoided
during homeopathic treatment
...
The focus of acupressure is to restore the balance of what?
a
...
Shiatsu
c
...
Ayurveda
ANS: A
Acupressure is focused on the return of the balance of Chi to control disease processes
...
A breastfeeding mother tells the nurse she is taking large doses of vitamin C to keep up her energy
...
Diarrhea
b
...
Colic
d
...

DIF: Cognitive Level: Comprehension REF: Page 767 OBJ: 5
TOP: Vitamin C KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Pharmacological Therapies
15
...
What is the nurses best response?
a
...
Hyperbaric oxygen therapy should have no harmful effect on your baby
...
No
...

c
...
Hyperbaric oxygen therapy is a much better option than using antibiotics
...
No
...

ANS: B
High concentrations of oxygen in the mothers blood can cause closure of the ductus arteriosus and cause fetal
death
...
A patient is providing history information to the admitting nurse about treatment used for chronic pain
...
What type of therapy
does the nurse record on admission record?
a
...
Biofeedback
c
...
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
...


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DIF: Cognitive Level: Comprehension REF: Page 765 OBJ: 9
TOP: CAM Therapies KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
MULTIPLE RESPONSE
17
...
)
a
...
Carbon monoxide poisoning
c
...
Decompression illness
e
...
HBOT is used to revive children with carbon monoxide poisoning, to aid wound healing,
and to treat the diving syndrome known as decompression illness
...

DIF: Cognitive Level: Knowledge REF: Page 769 OBJ: 13
TOP: HBOT KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
18
...
Which herbal products would the nurse educate this mother are safe to use in most of the pediatric
population? (Select all that apply
...
Ephedra
b
...
Fish oil
d
...
Aloe vera
ANS: B, C, D, E
Ginger, fish oil, chamomile and aloe vera are safe herbal products for children
...

DIF: Cognitive Level: Knowledge REF: Page 767-768, Table 34-3
OBJ: 11 TOP: Herbal Therapies
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk
19
...
)
a
...
Seasonal affective disorder
c
...
Stress disorders
e
...
Light therapy
is also used in the treatment of jaundiced babies
...
What advantage(s) of alternative health care should the nurse outline when providing information to

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320

patients? (Select all that apply
...
Offering more patient control of health care
b
...
Keeping patients from having to make decisions
d
...
Incorporating cultural beliefs and practices
ANS: A, B, D, E
Alternative health care actually promotes the patients decision making in care
...
Which approaches to care are combined with osteopathy? (Select all that apply
...
Manipulation therapy
b
...
Herbal application
d
...
Traditional medicine
ANS: A, D, E DIF: Cognitive Level: Knowledge REF: Page 763
OBJ: 9 TOP: Osteopathy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
22
...

ANS:
rolfing
Rolfing involves a process of stretching and placing pressure on the fascia to improve muscle and bone
function
...
While taking care of a Navajo child, the nurse welcomes their folk healer, called a ___________
...
These persons perform rites for
healing and well-being that are comforting to the Navajo
...
The nurse clarifies that a person who is ____________ _____________ demonstrates sensitivity and
respect for different practices and philosophies
...


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DIF: Cognitive Level: Comprehension REF: Page 761 OBJ: 5
TOP: Cultural Competency KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
25
...

ANS:
dermatomes
Dermatomes are areas of the skin that are innervated by the dorsal roots of the spinal cord
...

DIF: Cognitive Level: Knowledge REF: Page 764, Figure 34-4
OBJ: 8 TOP: Dermatomes KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation
26
...

ANS:
Aromatherapy
Aromatherapy is an ancient practice that involves concentrated fluid or the essence of specific herbs that are
combined with steams or baths to inhale or bathe the skin
...
In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the
various CAM therapies
...

ANS:
National Center for Complementary and Alternative Medicine (NCCAM)
In 1992 the National Institutes of Health (NIH) created the Office of Alternative Medicine to evaluate the
various CAM therapies
...
This Center serves as a public clearinghouse and resource for research concerning CAM
therapies

---