Maternal-Newborn Nursing: Common Questions and Answers, Exams of Nursing

Download Maternal-Newborn Nursing: Common Questions and Answers and more Exams Nursing in PDF only on Docsity! 1 ATI. MATERNAL-NEWBORN 1. Two days after delivery, a postpartum client prepares for discharge. What should the nurse teach her about lochia flow? Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21. Incorrect: Numerous clots are abnormal and should be reported to the physician. Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum hemorrhage. Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish brown, to creamy white. The color of the lochia changes from a bright red to white after four days Numerous large clots are normal for the next three to four days Saturation of the perineal pad with blood is expected when getting up from the bed Lochia should last for about 3 weeks, changing color every few days 2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late decelerations are suspected and the nurse notifies the physician. Which is the rationale for this action? Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late decelerations. Incorrect: Variable decelerations (not late decelerations) are associated with cord compression. Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of maternal contractions. Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign of fetal hypoxia. Repeated late decelerations indicate fetal distress. The umbilical cord is wrapped tightly around the fetus' neck The fetal cord is being compressed due to rapid descent of the fetal head 2 Maternal contractions are not adequate enough to deliver the fetus The fetus is not receiving adequate oxygen and is in distress 3. Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth? Incorrect: Monitoring O2 saturations and administering pain medications are postoperative interventions. Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions. Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made. Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case. Monitor oxygen saturation and administer pain medication. Assess vital signs every 15 minutes and instruct the client about postoperative care. Alleviate anxiety and insert an indwelling catheter. Perform a sterile vaginal examination and assess breath sounds. 4. Which nursing instruction should be given to the breastfeeding mother regarding care of the breasts after discharge? Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a result of the breast milk formation. The primary way to relieve engorgement is by pumping or longer nursing. Giving a bottle of formula will compound the problem because the baby will not be hungry and will not empty the breasts well. Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive amounts of lotion may harbor microorganisms. 5 8. Which site is preferred for giving an IM injection to a newborn? Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. Correct: The middle third of the vastus lateralis is the preferred site for injections. Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for injections in the newborn because of lack of muscle mass. Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to decreased muscle mass. Ventrogluteal Vastus lateralis Rectus femoris Dorsogluteal 9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding? Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period. Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of a UTI. Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and delivery, however the IV rates are carefully calculated according to weight. Correct: During pregnancy, the circulating blood volume increases by about 50%. In order to get rid of the excess fluid volume after delivery, the woman experiences an increased amount of urine output during the first few hours. Urinary tract infection High output renal failure Excessive use of IV fluids during delivery Normal diuresis after delivery 6 10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her blood sugar by diet alone, which medication will she receive? Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can cause damage to the fetus. They are not used in gestational diabetes for that reason. Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia. Clients with gestational diabetes have hyperglycemia. Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's blood sugar without harming the fetus. Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta and can cause damage to the fetus. They are not used for gestational diabetes for that reason. Metformin (Glucophage) Glucagon Insulin Glyburide (DiaBeta) 11. Which assessment finding indicates that placental separation has occurred during the third stage of labor? Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when the placenta separates. Incorrect: Contractions continue in an attempt to expel the placenta. The contractions may not be as intense, but they do not stop. Also, fundal massage helps contract the uterus preventing postpartum bleeding. Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the baby, but are not related to the placental detachment. They are a result of the release of pressure on pelvic nerves and the release of epinephrine during labor. Correct: As the placenta detaches, the cord that has been clamped becomes longer as it slides out of the vagina. Decreased vaginal bleeding Contractions stop Maternal shaking and chills 7 Lengthening of the umbilical cord 12. The nurse midwife is concerned about a pregnant client who is suspected of having a TORCH infection. Which is the main reason TORCH infections are grouped together? They are: Incorrect: Most TORCH infections can cause mild flu-like symptoms for the mother. Death may or may not occur in the fetus. Incorrect: TORCH is an abbreviation for Toxoplasmosis, Other (syphilis, HIV and Hepatitis B), Rubella, Cytomegalovirus, and Herpes simplex—not all of these are sexually transmitted. Correct: All TORCH infections have the capability of infecting the fetus or causing serious effects to the newborn. Incorrect: A vector is a carrier of the disease such as a mosquito. Not all of the TORCH infections are carried by vector. benign to the woman but cause death to the fetus. sexually transmitted. capable of infecting the fetus. transmitted to the pregnant woman by a vector. 13. During the postpartum period, a hospitalized client complains of discomfort related to her episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which nursing intervention is most appropriate during the first 24 hours following an episiotomy? Incorrect: Petroleum jelly will harbor bacteria, which may hinder healing. Incorrect: The client should practice Kegel exercises to increase bladder tone, but these exercises would add to the client's discomfort during the first 24hours.Incorrect: Taking a warm sitz bath is recommended after the first 24 hours. Correct: Ice packs will decrease edema and discomfort, and prevent formation of a hematoma. Instruct the client to use petroleum jelly on the episiotomy after voiding. Encourage the client to practice Kegel exercises. Advise the client to take a warm sitz bath every four hours. 10 "Vitamin K promotes bone and muscle growth." "Vitamin K helps the baby digest milk." "Vitamin K helps stabilize the baby's blood sugar." "Vitamin K is used to prevent bleeding." 18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally with her baby. Which response by the nurse is correct? Incorrect: Wrinkles do not form until late in the pregnancy. Fat stores usually do not form until the third trimester. Incorrect: The eyelids are fused until about 26 weeks. Correct: The kidneys are making urine, which is excreted by the fetus into the amniotic fluid. Incorrect: The heart is already formed and beating at 8 weeks. "The skin is wrinkled and fat is being formed." "The eyelids are open and he can see." "The kidneys are making urine." "The heart is being developed." 19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client demonstrates understanding of the instructions, stating she will notify the physician if which sign occurs? Incorrect: White vaginal discharge is a normal occurrence during pregnancy due to increased amounts of estrogen and increased blood supply to the cervix and vagina. It is not a “danger sign. “ Incorrect: Backache is common in pregnancy due to the alteration of the woman's center of gravity; it is not a “danger sign.” Backaches become worse as the uterus enlarges. Incorrect: Frequent, urgent urination is a common discomfort; it is not a danger sign. The pressure of the enlarging uterus causes frequency and urgency. 11 Correct: Abdominal pain is a danger sign and can be indicative of an abruptio placenta. It is important for a physician to evaluate this symptom. It is one of several danger signs, including: headache, rupture of membranes, vaginal bleeding, edema, epigastric pain, elevated temperature, painful urination, prolonged vomiting, blurred vision, change in or absence of fetal movement. White vaginal discharge Dull backache Frequent, urgent urination Abdominal pain 20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a newborn. The main objective of the treatment is to prevent infection caused by which organism? Incorrect: Erythromycin (Ilotycin) is an antibiotic ointment used to prevent blindness related to gonorrhea. Antibiotics are effective against bacteria. Rubella is a virus. Correct: Ilotycin, an antibiotic, is used for the prophylaxis treatment of gonorrhea and chlamydia. If left untreated, it could result in blindness. Incorrect: Ilotycin, an antibiotic, is not effective in combating syphilis infections. Incorrect: HIV is a virus. Antibiotics are effective against bacteria. Ilotycinis an antibiotic ointment and therefore not effective against HIV. Rubella Gonorrhea Syphilis Human immunodeficiency virus (HIV) 21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is given a half an hour before delivery, which effect will the medication have on the infant? It will cause the infant's: Incorrect: Narcotic analgesics cause respiratory depression and do not affect the infant's blood sugar. 12 Correct: Narcotic analgesics can cause respiratory depression for the infant and also for the mother. This is evidenced by low Apgar scores (apnea and bradycardia) in the infant. If respiratory depression occurs, a narcotic antagonist (Narcan) is usually given. Incorrect: Narcotic analgesics, if given too close to delivery, can cause bradycardia, not tachycardia. Incorrect: Narcotics, such as Demerol, cause CNS depression, not hyperactivity. blood sugar to fall. respiratory rate to decrease. heart rate to increase. movements to be hyperactive. 22. For a client in the second trimester of pregnancy, which assessment data support a diagnosis of pregnancy-induced hypertension (PIH)? Incorrect: A decrease in hemoglobin is indicative of anemia, while uterine tenderness may indicate abruptio placenta. Incorrect: Polyuria and weight loss are signs of gestational diabetes. Correct: PIH is characterized by two components: elevated blood pressure and proteinuria. Vasospasm in the arterioles leads to increased blood pressure and a decrease in blood flow to the uterus and placenta. This results in a questionable outcome for the fetus due to placental insufficiency. Renal blood flow is affected, ultimately resulting in proteinuria. Incorrect: Elevated blood glucose is a sign of gestational diabetes. Hematuria may indicate a U.T.I. Hemoglobin 10.2 mg/dL and uterine tenderness Polyuria and weight loss of 3 pounds in the last month Blood pressure 168/110 and 3+ proteinuria Hematuria and blood glucose of 160 mg/dL 23. A 35-week gestation infant was delivered by forceps. Which assessment findings should alert the nurse to a possible complication of the forceps delivery? 15 Incorrect: A para of 4 would be obtained by incorrectly counting the 2 spontaneous abortions as viable at delivery. Gravida 2, para 3 Gravida 4, para 2 Gravida 5, para 2 Gravida 5, para 4 27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important? Incorrect: Although this addresses the client's nausea and vomiting, it is not the most important diagnosis at this time. There are no data to indicate that the client actually has a nutritional deficit. Because nausea and vomiting place her at risk for nutritional deficit, a diagnosis of “risk for altered nutrition. . .” would be appropriate. The knowledge diagnosis is an actual problem and should be addressed at this contact with the client; the nutrition problem will be ongoing during the pregnancy. Incorrect: This diagnosis does not address the reason for the lack of client knowledge—she may be at risk for poor parenting, but this is not the priority because there will be time to address that issue as the pregnancy progresses. Incorrect: There is no clear evidence of the denial of pregnancy nor of the lack of coping skills. Correct: This client clearly has a knowledge deficit about the causes of pregnancy and the physiological changes associated with it. It is important for teaching to begin immediately because her understandings essential to her compliance with suggestions for a healthy pregnancy. Altered nutrition: less than body requirements related to nausea and vomiting Risk for altered family processes related to the client's age Ineffective individual coping related to denial of pregnancy Knowledge deficit related to the client's developmental stage and age 16 28. A client is admitted to the hospital for induction of labor. Which are the main indications for labor induction? Incorrect: These are contraindications for labor induction. Correct: Induction of labor is the stimulation of contractions (usually by the use of Pitocin) before they begin on their own. Maternal indications for induction of labor include: pregnancy induced hypertension, chorioamnionitis, gestational diabetes, chronic hypertension and premature rupture of membranes. Fetal indications include intrauterine growth retardation, post-term dates and fetal demise. Incorrect: These are contraindications for labor induction. Incorrect: These are contraindications for labor induction. They are indications for a C-section. Placenta previa and twins Pregnancy-induced hypertension and postterm fetus Breech position and prematurity Cephalopelvic disproportion and fetal distress 29. A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics? Incorrect: This choice describes general anesthesia. Correct: Regional anesthetics provide numbness and loss of pain sensation to an area. The most common regional blocks are: local, pudendal, epidural, and spinal. Incorrect: Pain sensations travel to the central nervous system not away from it. Incorrect: This choice describes the action for narcotic medications, not regional anesthetics. To relieve pain by decreasing the client's level of consciousness To provide general loss of sensation by blocking sensory nerves to an area To provide pain relief by blocking descending impulses from the central nervous system To relieve pain by decreasing the perception of pain leading to the pain centers in the brain 17 30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant: Incorrect: Usually babies that only need suctioning of the mouth and nose have Apgars that are 8 or 9. Incorrect: If intubation is required, it means that the baby's heart and respiratory rates are not stable, and Apgars would be lower than 5. Incorrect: Apgar scores are used to quickly assess the well-being of the baby. Apgar scores range from 0-10. A score of 0 indicates that the baby is dead. An Apgar score of 5 indicates that the baby needs assistance. Correct: Apgar scores of 5 and 7 indicate that the heart rate was below 100, the respiratory effort was irregular, there was little muscle tone, the baby was pink with blue extremities, and there was a grimace. These scores indicate that the baby needed stimulation in order to breathe, and oxygen to increase its oxygen saturation. needed brief oral and nasal suctioning. required endotracheal intubation and bagging with a hand-held resuscitator. was stillborn and required CPR. required physical stimulation and supplemental oxygen. 31. With routine prenatal screening, a woman in the second trimester of pregnancy is confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin in the management of blood sugar during pregnancy? Correct: Insulin is given to gestational diabetic clients because their insulin requirements cannot keep up with the metabolic needs of the fetus in the last trimester. Insulin decreases the blood sugar. Incorrect: Oral hypoglycemic agents are not given to clients with gestational diabetes because they cross the placenta and are harmful to the fetus. Incorrect: The client will need frequent follow-up after delivery and into the postpartum period, but she should not need insulin after delivery because in gestational diabetes, blood glucose usually returns to normal after delivery. Incorrect: Clients with gestational diabetes need to eat three balanced meals and three snacks daily. The glucose load is best when maintained at a steady level throughout the day to avoid 20 35. The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure? Incorrect: Maternal oxygenation is not affected by an amniotomy. Incorrect: Maternal pulse and blood pressure are not affected by an amniotomy. Incorrect: Assessing the perineum should be done after an episiotomy, not after amniotomy. Correct: An amniotomy, or artificial rupture of membranes (AROM), is used to speed up labor. The nurse must document the color, amount, character and odor of the fluid, and assess for fetal well being. Check the client's capillary refill and oxygenation. Monitor the maternal pulse and blood pressure. Inspect the perineum for lacerations, bleeding, and hematoma. Assess the fluid for color, odor, and amount. 36. For a pregnant adolescent who is anemic, which foods should the nurse include In the client's dietary plan to increase iron levels? Incorrect: Milk does not contain iron and it interferes with iron absorption. Correct: Orange juice enhances the absorption of iron. Apricots are a good source of iron. Incorrect: Chicken does contain iron, but cottage cheese, a dairy product, does not. Incorrect: Pickles contain large amounts of salt, not iron. Peanut butter sandwiches do not contain much iron. Milk and fish Orange juice and apricots Chicken and cottage cheese Pickles and peanut butter sandwiches 37. Which condition must occur in order for identical (monozygotic) twins to develop? Incorrect: Usually only one ovum is released per month; one sperm cannot fertilize two ova. 21 Incorrect: This is the case in fraternal (dizygotic) twins. There are two placentas, two chorions, and two amnions. The twins may be the same or different sex. Correct: One sperm fertilizes one ovum, and then the zygote divides into two individuals with one placenta, one chorion, two amnion and two umbilical cords. These twins are always the same sex. Incorrect: The enzyme on the head of the sperm dissolves the coating of the ovum so eventually only one sperm penetrates one egg. One sperm fertilizes two ova Two sperm fertilize two ova One sperm fertilizes one ovum Two sperm fertilize one ovum 38. Which fetal structure is responsible for carrying oxygenated blood from the placenta to the fetus? Incorrect: The ductus arteriosus is a shunt that connects the lungs to the aorta, allowing the blood to bypass the lungs. Incorrect: Except in the case of fetal circulation, arteries do carry oxygenated blood; but during pregnancy, the two umbilical arteries carry unoxygenated blood from the fetus to the placenta, where preoxygenation occurs. Incorrect: The portal vein carries blood from the intestine to the liver. Correct: The umbilical vein carries oxygenated blood from the placenta to the fetus. The direction of blood flow is toward the fetal heart. Ductus arteriosus Umbilical artery Portal vein Umbilical vein 39. A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor in the client's history supports this diagnosis? The client states that she: 22 Incorrect: Drinking alcohol is not usually associated with abruptio placenta. Incorrect: Clients with abruptio placenta do not have contractions that can be relieved by walking. Usually the pain is quite intense. Incorrect: Intercourse should not cause an abruptio placenta, although it is contraindicated in clients with placenta previa. Correct: The use of crack cocaine is associated with the separation of the placenta and the bleeding/ hemorrhage that results. Cocaine use is not usually an isolated incident, so the nurse should ask the client about the frequency/amount of the drug usage. drinks two glasses of wine before dinner every night. has intermittent contractions that are relieved by walking. had intercourse with her partner last night. used crack an hour before the symptoms began. 40. Which explanation is most appropriate when describing physiological jaundice to the parents of a newborn? Incorrect: Pathological jaundice, not physiological jaundice, occurs within the first 24 hours and is a result of an ABO incompatibility or Rh incompatibility. Correct: Physiological jaundice is the result of the breakdown of excessive amounts of red blood cells that are not needed after birth. Physiological jaundice is also related to the inability of the immature liver to rid the body of bilirubin, which occurs as the red blood cells are broken down. The bilirubin accumulates in the blood causing it to be yellow. Incorrect: Jaundice related to breast milk occurs after the first 7 days, not within the first three. It is not the cause of physiological jaundice. Incorrect: Hepatitis B may have been acquired during delivery and may cause jaundice, but it is not the cause of physiological jaundice, which this case represents. "The baby has a minor incompatibility of the blood." “The baby is breaking down the extra red blood cells that were present at birth.” “The baby is getting too much breast milk, but this is not dangerous.” “The baby may have gotten exposed to hepatitis B during the delivery.” 25 Incorrect: The warmer does provide easy access for the family, but this is not the main reason for its use. To facilitate an efficient means of thermoregulation To facilitate initial assessment by the nurse To permit the use of the cardiac monitor To permit close observation by the family members 45. A client, gravida 1, para 0, in active labor, is becoming increasingly anxious. Which statement by the nurse will block therapeutic communication with the client? Incorrect: Since this is the client's first baby, there will be concerns/anxiety because of the unknown expectations. This response is appropriate, and will help decrease anxiety by allowing identification and ventilation of fears. Incorrect: This response will encourage the client to talk and will foster good communication. Correct: This is an example of meaningless reassurance and will block therapeutic communication because the needs of the client are not being met. Incorrect: This response will facilitate communication, not block it. "What concerns are you having now?" "Tell me how you are feeling." "Everything is going just fine." "You seem a little nervous." 46. A nurse prepares to teach a class regarding postpartum care and includes infections in the teaching plan. Which is the main cause of mastitis in the postpartum client? Correct: Poor breast-feeding technique and improper positioning of the baby are the main reasons for mastitis. Improper release of the baby's suction can lead to sore, cracked nipples, creating a portal of entry for pathogens. Incorrect: Poor hand washing is not the main reason that a woman gets mastitis but can be a contributing cause. For example, if the woman touches her perineal pad and then the breast, the bacteria on the hands can cause an infection. 26 Incorrect: Systemic infections such as flu or cold are not the cause of mastitis, which is a localized infection. Incorrect: Prolonged nursing by itself does not cause mastitis. Often babies engage in nonnutritive sucking. Poor breast feeding technique Inadequate hand washing Systemic maternal infection Prolonged nursing 47. A postterm infant is delivered by cesarean section because of fetal distress and meconium- stained amniotic fluid. The nursery nurse frequently monitors the baby's respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The infant may: Incorrect: Respiratory depression does not result in tachypnea but in apnea. Correct: This infant is a risk for meconium aspiration pneumonia related to post maturity, meconium staining, fetal distress and being delivered by c-section. Incorrect: Infants with respiratory distress (tachypneic) are usually cold stressed and hypothermic, not hyperthermic. Incorrect: A pneumothorax usually is seen in premature infants who lack surfactant. experience respiratory depression from the medications used during delivery. develop meconium aspiration pneumonia. have an elevated temperature. have a pneumothorax related to delivery. 48. The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action is appropriate? Incorrect: Hyperventilation is not the cause of the variable decelerations. Incorrect: Hypertonic uterine contractions refer to a labor with very painful but not necessarily effective contractions. The uterus does not relax between contractions. This leads to fetal distress and results in late decelerations, not variable decelerations. 27 Correct: Variable decelerations are a result of cord compression. Turning the client onto her left side may improve fetal oxygenation by relieving pressure on the cord. Incorrect: Variable decelerations are a result of fetal cord compression. Decreasing the fluids will not relieve cord compression. Instruct the mother to breathe slowly because this is a sign of hyperventilation. Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions. Turn the woman onto her left side to relieve pressure on the umbilical cord. Reduce the oral and IV fluids to decrease circulatory overload. 49. The nursery nurse delays the first bottle feeding of a newborn. Which is the most common reason for the nurse's actions? The infant has: Incorrect: One method of increasing an infant's low blood sugar is by feeding him. Correct: Bottle feeding of an infant who is tachypneic (resp. rate > 60) is contraindicated due to risk of aspiration. Incorrect: Acrocyanosis (blue hands and feet) is a normal finding for the first 24 hours. Incorrect: It is not unusual for the nurse to hear a heart murmur shortly after birth. a blood glucose of 45 gm/dL. a respiratory rate above 60. blue hands and feet. a heart murmur. 50. During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the woman's perineum and observes a prolapsed cord. Which nursing action is most appropriate? Correct: With a sterile gloved hand, the nurse should push the presenting part away from the cord, thus preventing cord compression. The cord supplies the fetus with oxygen and nutrients. The fetus is already showing signs of distress because of the slowing of the heart rate. In addition, the nurse should prepare for immediate delivery. Incorrect: Since the head is not engaged (which is why the cord prolapsed), it will be very difficult to insert a scalp electrode. 30 54. Which information is most important for the nurse to gather when a client is admitted to the unit in labor? Incorrect: This is useful information, but the priority information is that regarding medical conditions which may create serious risks to the fetus and mother. Correct: Asking the client about any medical problems should be the priority because it provides a quick assessment for risks to the fetus and mother. Incorrect: Fluids are given in the latent phases of labor, but gathering this information at the initial admission interview is not as important as obtaining information about medical conditions which may create serious risks to the fetus and mother. Incorrect: This is not important unless the client has PIH or a cardiac condition. Even then, the initial assessment would be to find out if the client actually has PIH or cardiac condition (e.g., by checking the history), not to diagnose it. Name of the support person Medical problems or complications Fluid preferences Amount of weight gained during the pregnancy 55. The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should this assessment finding be documented? Incorrect: Bruising usually does not involve the scrotum, and is not usually gray. Correct: Mongolian spots are the result of increased pigmentation over parts of the baby. They are most commonly found in infants of Asian, Indian, African-American or Mediterranean descent. They are harmless and fade during the first two years of life. Incorrect: Nevus flammeus is a dark red lesion called a port wine stain. It does not blanch when touched, and does not fade with age. This type of hemangioma usually is seen on the face or thigh rather than the back. Incorrect: Acrocyanosis, a normal finding, is a bluish discoloration of the hands and feet (not the back or buttocks), and is related to sluggishness of the peripheral circulation. Extensive bruising 31 Mongolian spots Nevus flammeus Acrocyanosis 56. A small-for-gestational-age infant is irritable and jittery, and has hyperreflexia and clonus. He is jaundiced, has temperature instability, and spitty after feedings. The nurse suspects the infant is displaying signs of passive addiction during pregnancy. When planning for the infant's care at home, which nursing assessment is most important for the infant experiencing neonatal abstinence syndrome? Correct: In cases of maternal drug addiction, it is very important that the home situation be assessed because infant abuse and neglect are common in homes where there is drug/alcohol abuse. Incorrect: While this may be important information to know, it does not address the infant or its care. Incorrect: Assessing whether or not the mother has money enough to afford treatment for her addiction is not as important as the infant's safety. Incorrect: Drug withdrawal is not measured in degree of severity. The baby is withdrawing, and that is all that is important. The mother's ability to provide a safe environment The extent of addiction of the mother The mother's ability to obtain treatment The severity of the infant' s withdrawal 57. A woman in active labor is admitted to the labor and delivery unit, accompanied by her partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in the corner, looking out the window. How may the nurse understand the man's actions? Incorrect: Other factors such as culture, personality, and language should be considered before assessing the inability to cope due to overwhelming concern for the woman. At this point there are no data to indicate overwhelming concern. 32 Correct: These factors must first be considered along with ability to speak the language. Keeping in mind that there are individual and cultural differences in expressing concern will enable the nurse to make unbiased assessments. Incorrect: Embarrassment may be a reason for the man's actions, but is not the first consideration. It is important to first consider that there individual and cultural differences in expressing concern. This will enable the nurse to make unbiased assessments. Incorrect: If a man's religious beliefs prohibited him from viewing a birth, he is not likely to be in the room during the active phase of labor. He is likely to be very concerned about the woman's health to the point that his ability to cope with the situation is compromised. His actions reflect personality or cultural differences, which do not necessarily indicate a lack of concern. Due to his embarrassment and discomfort regarding the woman's expressions of pain, he withdraws from the situation. His religious beliefs regarding participation in the birth experience affect his interactivity and communication in this situation. 58. A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug? Correct: Because hypertension is a sign of PIH, the client's BP must be monitored. The client's respiratory rate should be monitored because one sign of magnesium sulfate toxicity is a respiratory rate under 12/min. Incorrect: Assessing blood glucose levels does not pertain to PIH but to gestational diabetes. Incorrect: A side effect of magnesium sulfate is a decrease in blood pressure, which might cause orthostatic hypotension; however, the client with severe PIH will be on strict bed rest and not allowed to walk. Incorrect: Magnesium sulfate may be used for preterm labor to slow contractions, but this does not pertain to PIH. Assess blood pressure and respiratory rate every fifteen minutes. Monitor blood glucose levels every eight hours. 35 date November 7th.Incorrect: Seven days have been subtracted instead of added to the LMP. November 31 December 7 November 7 December 24 63. Which procedure should be avoided for the client known to have a placenta previa? Incorrect: Non-stress tests are necessary to monitor the well-being of the fetus. Non-stress tests are usually performed if the client returns home after a bleeding episode. Incorrect: Performing a catheterization has nothing to do with placenta previa. Correct: In placenta previa, the placenta covers all or part of the cervical opening. Therefore, vaginal exams are contraindicated because of risk of bleeding or infection. Hemorrhage is the main complication of placenta previa. Incorrect: Abdominal ultrasounds are non-invasive and are commonly performed upon admission to the hospital to locate the position of the placenta. A non-stress test A urinary catheterization A sterile vaginal exam An abdominal ultrasound 64. A woman in the first trimester comes to the clinic with vaginal bleeding. The physician determines that the fetus has died and that the placenta, fetus, and tissues still remain in the uterus. How should the findings be documented? Incorrect: A complete abortion occurs when all products of conception are expelled. Incorrect: Stillborn is a lay term that means the baby has died. This does not address the products of conception such as the placenta or tissues. 36 Correct: Prolonged retention of the products of conception (placenta/tissues) after the fetus has died is known as a missed abortion. Infection and coagulation defects are common complications. Incorrect: An incomplete abortion occurs when some, but not all, of the products of conception have been expelled. Complete abortion Stillborn abortion Missed abortion Incomplete abortion 65. A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms? Incorrect: Anoxia/hypoxia results in restlessness, nasal flaring, and cyanosis of the lips and nailbeds. The signs and symptoms listed in the question are not related to anoxia. Correct: These signs and symptoms are a result of hyperventilation. The nurse should have the client breathe slower and into a paper bag to counteract the signs and symptoms. Incorrect: Anxiety usually causes rapid heart rate and muscle tenseness, not the symptoms listed in the question. Incorrect: While hypertension often affects vision, it is not the reason for this cluster of signs and symptoms. Anoxia Hyperventilation Anxiety Hypertension 66. Which data support a diagnosis of abruptio placenta in a pregnant woman? Correct: These are classic signs of an abruptio placenta. Other signs and symptoms include: dark, red vaginal bleeding, fetal distress, signs of hypovolemic shock. 37 Incorrect: These are signs of placenta previa, not abruptio placenta. Incorrect: These have nothing to do with abruptio placenta. Incorrect: Bright red blood loss is a sign of placenta previa. Hypertension may occur in abruptio placenta, however. Uterine rigidity and abdominal pain Painless bleeding with soft abdomen Premature rupture of membranes and uterine contractions Bright red blood loss and elevated blood pressure 67. A women in her first trimester contracts rubella. How is the fetus likely to be affected? Incorrect: Rubella is usually associated with hearing, vision and cardiac defects. Correct: The rubella virus usually causes mild illness in the mother, but has devastating effects on the fetus, including cataracts, heart defects (patent ductus arteriosus and pulmonary stenosis are the most common), deafness, mental and motor retardation, growth retardation and clotting disorders. Incorrect: Spinal cord defects are a result of the inability of the vertebrae to fuse—it is a congenital problem and not related to rubella. Incorrect: Polydactyly, the presence of extra digits (fingers or toes), and club feet are not usually seen in fetuses with rubella. Reproductive and urinary defects Heart defects and cataracts Spinal cord and skeletal defects Polydactyly and club feet 68. An hour after delivery, a 4000 gram infant exhibits pallor, jitteriness, a blood sugar level of 40 gm/dL, irritability and periodic apnea. Which maternal condition could be the cause of the newborn's symptoms? Incorrect: Jitteriness and irritability may indicate a drug withdrawal problem, but the large birth weight and the low glucose levels indicate an infant of a diabetic mother. 40 72. A new mother is crying in her room. She tells the nurse that her new baby boy has enlarged breasts and she thinks that there is something wrong. How should the nurse respond? Incorrect: This statement would increase the client's worry and anxiety by confirming her fears that something is wrong. The baby's symptom is completely normal. Correct: Enlarged breasts are common as a result of hormonal withdrawal. Breast enlargement usually subsides within the first few weeks after delivery. This response provides the mother with information, which should decrease her anxiety. Incorrect: This may be an appropriate response, but should not be the nurse's first response because it suggests the possibility that something is wrong with the baby. The baby's symptom is completely normal. Incorrect: This statement is an example of meaningless reassurance. "You should ask your doctor about that." "Enlarged breasts are common for both boys and girls. It will go away." "Let me look at the baby for you." "Everything is going to be just fine. Your baby is healthy." 73. During the active phase of labor, the membranes rupture and the nurse notes green amniotic fluid. Which nursing action should be initiated immediately? Incorrect: Green amniotic fluid is an indication of meconium staining, which may indicate fetal distress. The physician should be notified but not before assessing the status of the fetus. Incorrect: This is a comfort measure. It can wait until after the nurse assesses for fetal distress. Incorrect: Testing the fluid usually differentiates amniotic fluid from urine. Correct: Any time the membranes rupture, the nurse should immediately assess fetal heart rate, especially when the fluid is meconium stained, as this may indicate fetal distress. Call the physician. Replace the soiled underpad. Test the fluid with pH (Nitrazine) paper. Assess fetal heart rate. 41 74. At 28 weeks gestation, a woman enters the hospital in preterm labor and receives atocolytic medication to stop labor. Which assessment findings should be reported immediately to the physician? Incorrect: Fetal heart rate of 160 is considered normal. Incorrect: These represent Braxton Hick contractions, not true labor. Contractions should be monitored closely for intensity, frequency and duration. Incorrect: The vital signs are within normal limits. Correct: Ferning is an indication of amniotic fluid, which indicates that the membranes are ruptured. This should be reported immediately because delivery may be imminent. With ruptured membranes, the client should be monitored for infection. Fetal heart rate averaging 160 beats/min Irregular contractions every 15-20 minutes that last 30 seconds before stopping Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70 Ferning pattern of vaginal discharge under a microscope 75. A labor and delivery nurse suspects that a client is in the transition stage of labor. Which information supports this conclusion? The client is: Incorrect: These are typical signs of the latent or early phase of labor. Correct: These are typical signs of the transition phase of labor. In addition to irritability and the inability to focus, the client may exhibit anger, loss of control, anxiety, mood swings, rectal pressure, and increasing amounts of pain. Incorrect: These occur in the second stage of labor, just prior to birth. Incorrect: These are signs that the client is in the latent or early phase of labor. walking around the unit and talking with her partner. irritable and needs frequent repetition of directions. expelling feces and the fetal head is crowning. reading a magazine and talking on the phone. 42 ATI. CHILD CARE 2.0 1 The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the food comes out of the infant's mouth and onto his clothes. Which of the following explanations should the nurse give to the parents? Trying to introduce food after the intake of a bottle formula is usually not recommended because the infant is satiated and has no inclination to try something new. Solid foods should be offered at 4 to 6 months. The gastrointestinal tract has matured enough to handle more nutrients and is less sensitive to potentially allergenic foods. This deprives the infant of the pleasure of learning new tastes and developing a discriminating palate. It may cause problems with poor chewing because of lack of experience. Due to the extrusion (protrusion) reflex, the infant’s tongue pushes the food out of the mouth. It is most helpful to suggest using a long-handled spoon and placing the food in the back of the infant's mouth to avoid the reflex. 45 "I will call the Poison Control Center." "I will get my child to drink a full glass of water." 6 A nurse is caring for a 23-month-old child with iron-deficiency anemia. The parents indicate they have been taught about the diagnosis, but are concerned that they are not doing all that they need to do. Which of the following should the nurse include when reinforcing teaching? Cow's milk contains substances that bind with iron and interfere with its absorption. Iron should not be given with milk or milk products. There are no food limitations or suggestions when children are taking oral iron preparations. Foods with vitamin C, such as citrus fruits, enhance the absorption of iron. Oral iron supplements do not cause GI bleeding or ulcers. Liquid iron may stain the teeth, so the nurse should instruct the parents to give it through a straw placed in the back of the child's mouth to avoid staining the teeth. Give the oral iron supplementation with a glass of cow's milk to prevent stomach problems. Provide diet instructions including limiting citrus fruits in favor of more vegetables. Provide information about complications of iron including gastrointestinal bleeding and ulcers. Give liquid iron through a straw placed in the back of the mouth. 7 A nurse is reviewing discharge teaching with the parents of a child who has pediculosis. Which of the following should the nurse include in the teaching? Children should not share combs, hair ornaments, hats, caps, scarves, coats, and other items used on or near the hair. Pets are not carriers of lice. Clothes should be dried in a hot dryer for at least 20 min to kill the lice. Lice need a blood source to survive. Placing the nonwashable items in a sealed plastic bag for 14 days will kill the lice. "Children can share scarves and coats, but not hats or combs." "Household pets can carry and transmit lice to people." "After washing clothing, hang clothes outside to dry." "Seal nonwashable items in plastic bags for 14 days." 8 A nurse is caring for a toddler who is in an oxygen tent. Which of the following actions should the nurse take in order to promote comfort while maintaining the child's safety? 46 Not all toys are safe to put inside an oxygen tent. Vinyl or plastic toys that do not absorb moisture are suitable to put inside the tent. Stuffed animals absorb moisture and are difficult to dry. High levels of oxygen are a source of sparks, so mechanical or electrical toys are a potential fire hazard. The moisture inside an oxygen tent will make the child cold and the child’s clothes moist. Therefore, the nurse should try to keep the child warm and dry by changing bedding and clothes, which will enhance the child's comfort without compromising safety. Oxygen is heavier than air; therefore, oxygen loss will be greater at the bottom of the tent. The tent should be tucked snugly without open edges to prevent oxygen loss. Some tents are opened at the top. Oxygen is a heavy gas and most of it will stay at the bottom of the tent. This measure does not promote the child's comfort while in the oxygen tent. Give the child a stuffed animal and car with rubber wheels to play with. Change the bedding and the child's clothing frequently or as often as needed. Tuck the bottom of the tent under the mattress on three sides, leaving one side open so the child can look out. Cover the opening on the roof of the tent with a blanket to prevent the child from becoming chilled. 9 A nurse is reinforcing teaching with the parent of a child with a urinary tract infection. Which of the following statements made by the parent indicates understanding of how to prevent future infections? Children should be encouraged to void frequently, especially before long trips or other circumstances in which toilet facilities may not be available for an extended period of time. Urine that is held can harbor bacteria that can result in a urinary tract infection. Cotton underwear allows for more air flow to the perineal area and reduces the risk of urinary tract infections. Wiping from back to front increases the risk of feces entering the urethra and causing a urinary tract infection. Bubble baths and perfumed perineal products can irritate the urethra and lead to a urinary tract infection. These should be avoided, especially for girls. "I will bring my child to the bathroom before we leave for extended trips." "I need to switch my child from cotton underwear to nylon underwear." "I should teach my child to wipe from back to front after urinating." "I will have my child soak in a bubble bath once or twice a week." 47 10 A nurse is reviewing discharge instructions with the parent of an infant who has acute laryngotracheobronchitis (croup). Which of the following statements made by the parent indicates a need for further teaching? This is a correct intervention. Corticosteroids have an anti-inflammatory effect that decreases subglottic edema. This will make breathing easier. This is a correct intervention. Clearing the nasal passages decreases the amount of secretions in the upper and lower airways. Dry air will exacerbate the child's croup. Cool temperature therapies are advocated for this condition. Cool mist constricts edematous blood vessels. A cool air vaporizer can be used at home to maintain high humidity and provide relief. Warm mist from warm running water such as a hot shower in a closed bathroom may be beneficial. It is essential that children with laryngotracheobronchitis (croup) be allowed and encouraged to drink any fluids they like to increase fluid intake. "I will give my child the corticosteroids prescribed by the doctor." "I will clear the child's nasal passages with a bulb syringe to aid in breathing." "I will place a dehumidifier in my child's room." "I will encourage my child to take plenty of fluids over the next several days." 11 A 15-year-old client visits the clinic to get medical clearance to play a sport. The nurse reviews measures to prevent athlete's foot with the client. Which of the following statements by the client indicates that the instructions were understood? Many people believe tinea pedis is transmitted via showering in the same location as someone who is infected. However, transmission of tinea pedis to other individuals is rare. Ointments have not proven to be successful in treating tinea pedis. Application of antifungal powder containing tolnaftate or tolnaftate liquid is a treatment measure. Medication is not usually recommended as a preventative measure. The client should avoid heat and perspiration by wearing light socks. Wearing well-ventilated shoes and clean, lightweight socks is encouraged in order to prevent heat and perspiration conditions. Occlusive shoes should be avoided. "I will avoid showering at the gym." "I can apply an antifungal cream daily." "I should wear dark-colored socks." "I should wear well-ventilated shoes." 50 The vastus lateralis is the preferred site for IM injections in infants. The deltoid muscle is not the preferred site for IM injections in infants. It is recommended that the ventrogluteal site not be used until infants begin walking. 17 A nurse is reinforcing teaching with the parent of an infant who has club feet with bilateral casts. Which of the following statements should be included in the teaching? If a cast is too tight, circulation will be impaired and the toes will swell. Serial manipulation and casting allows for the gradual stretching of skin and accommodates the rapid growth in early infancy, and is performed every week for 8 to 12 weeks. If normal alignment is not achieved by 3 months, surgical intervention is indicated and will take place at about 6 to 12months of age. It can take 24 to 48 hr for the cast to dry completely. A regular fan or cool-air hair dryer to circulate air may facilitate drying when humidity is high. Heated fans and dryers should not be used because they can cause the cast to dry on the outside but remain wet on the inside. They may also cause burns from the conduction of heat from the cast to the underlying tissue. Pain is not a problem associated with casting for club feet. "Check the toes for any swelling or discoloration." "Monthly recasting should be scheduled with the orthopedist." "Use a heated fan or dryer to facilitate the drying of the cast." "Give the baby Tylenol every 4 hr to help with pain." 18 A nurse is caring for a child with measles. Which of the following actions is appropriate supportive care? Photophobia accompanies rubeola; therefore, diversional activities with bright lights are contraindicated. Dimming the room lights is soothing for the child. Isolation should be until day 5of the rash. The period of communicability is from 4 days before the appearance of the rash until5 days following the appearance of the rash. An elevated temperature is common. Overheating, which increases itching, should be avoided. The child should wear lightweight, loose, and nonirritating clothing, and keep out of the sun. Antipyretics should also be administered. Vitamin A supplementation reduces the morbidity and mortality in children with the measles. Children with measles should be given vitamin A supplements. Nurses need to instruct parents on safe storage and administration of vitamin A to prevent excessive administration and possible toxicity. Provide diversional activities such as video games. 51 Maintain isolation for 48 hr after the rash resolves. Keep the child warm with adequate undergarments and bedding. Administer vitamin A supplements as prescribed. 19 A nurse is caring for a 14-year-old client diagnosed with diabetes mellitus. The nurse is discussing the ongoing monitoring needed with this diagnosis. Which of the following should be included in the discussion? When children are ill their fluid intake should be monitored. They often drink less, leading to dehydration. When children are hyperglycemic, dehydration from illness leads to increased hyperglycemia and requires extra fluid intake. Exercise results in increased movement of glucose into the cells and decreased blood glucose levels. The client should have a snack, not additional insulin. There is poor correlation between glycosuria and blood glucose. Blood glucose monitoring is much more accurate than urine glucose monitoring. Children with diabetes should increase the amount of whole grains, fruits, and vegetables, which contain complex carbohydrates, in their diets. Concentrated sweets are avoided to prevent hyperglycemia. The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration. Exercise requires additional insulin since glucose will be released from the cells during activity. Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations. The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose. 20 A nurse is reinforcing teaching with the parent of a 4-year-old child with influenza. Which of the following should the nurse include in the teaching? Influenza is spread by direct contact. This means it can be spread from one person to another or by touching an object that has been contaminated by nasopharyngeal secretions. The most infectious period for influenza is 24 hr before and after the onset of symptoms. There is a possible link between aspirin and Reye syndrome, so children with influenza or other viral illnesses should not be given aspirin. Most cases of Reye syndrome follow a common viral illness such as chickenpox or influenza. The immunization vaccine can be given at the same time as other vaccines, but must be given in a separate syringe and at a different injection site. Influenza is transmitted by airborne means, so handwashing will not prevent transmission. 52 Children are not infectious after 12 hr from the onset of influenza symptoms. Aspirin should not be given to children with influenza for relief of discomfort. The influenza vaccine may not be given at the same time as other immunizations. 21 A nurse is discussing nutrition with an adolescent who is pregnant. The adolescent's parent is in the room. Which of the following statements made by the parent indicates a need for further dietary instruction? This statement needs clarification. Snacks containing sugar are often eaten by the adolescent who is pregnant, but are not a good source of calories for energy and nutrition for the developing fetus. Whether pregnant or not, an adolescent's nutritional needs include an increase in calcium, protein, and iron. Nutritious between-meal snacks are a good source of energy. Complex carbohydrates of wheat and whole grains and fruits are appropriate snacks. This is a good suggestion because the adolescent does need additional calories in the second and third trimester. "I told my daughter that any calories ingested are a source of energy and nutrition." "I try to provide foods with an increased amount of calcium, protein, and iron." "I encourage between-meal snacks that are complex carbohydrates and fruits." "I have planned meals and snacks for additional calories in the second and third trimester." 22 A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first? Even though continued pain assessment is important, this is not the first priority with the sudden relief of pain. The child's vital signs will need to be taken before surgery, but this is not the priority at this time. The sudden cessation of pain in a child with appendicitis should cause the nurse to suspect a ruptured appendix. The primary care provider should be notified immediately since the client is at increased risk for developing peritonitis, which can cause death if appropriate interventions are not immediately taken. The nurse would assess bowel sounds as the child is prepared for surgery, but this is not the priority at this time. Continue with the pain assessment. Take the child's vital signs. Notify the primary care provider. 55 mL First, convert the client's weight to kg: 2.2 lb = 1 kg, so 22 lb = 10 kg. 24 hr/day = 3 doses/day 8 hr/dose 30 mg/kg/day = 10 mg/kg/dose 3 doses 10 mg x 10 kg = 100 mg every 8 hr The desired dose is 100 mg. The medication is available as 200 mg/5 mL. 100 mg/x mL = (½)5 mL 200 mg/5 mL 5 mL = 2.5 mL/dose &nbsp2 First, convert the client's weight to kg: 2.2 lb = 1 kg, so 22 lb = 10 kg. 24 hr/day = 3 doses/day 8 hr/dose 30 mg/kg/day = 10 mg/kg/dose3 doses 10 mg x 10 kg = 100 mg every 8 hr The desired dose is 100 mg. The medication is available as 200 mg/5 mL. 100 mg/x mL = (½)5 mL200 mg/5 mL 5 mL = 2.5 mL/dose&nbsp2 28 Which of the following approaches is the most accurate way to measure the heart rate of a 10month-old infant? The apical heart rate is auscultated and is the most accurate measurement for an infant. The radial pulse is not palpable in an infant. The ulnar vein is deep in the arm and is not palpable. The brachial pulse is palpable in an infant. It provides a quick check of circulation status, but it is not the most accurate approach. Apical Radial 56 Ulna Brachial 29 A nurse is caring for a 4-year-old child diagnosed with leukemia who is admitted with myelosuppression. Which of the following actions should the nurse take? High carbohydrates will not provide the proper nutrients for protection against infection. The child needs a diet high in protein for defense against infection. Chemotherapy can cause injury to mucous cells lining the rectal area, making this area prone to ulceration and tears. Rectal temperatures should be avoided to prevent trauma to this fragile tissue. Lemon and glycerin swabs are abrasive and can irritate tissue. A break in the skin is a potential source of infection. Provide a diet high in carbohydrates. Monitor rectal temperature every 4 hr. Use lemon or glycerin swabs for oral care. Inspect the skin daily for lesions. 30 The parents of a 4-year-old child state that they had an infant die 2 months ago during childbirth. They are concerned about their 4-year-old child's response to the infant's death. Which of the following statements by the parents indicates an expected response about death from the 4- year-old child? This expresses a more adult understanding of death. Preschoolers tend to think that the sibling is still alive. This kind of question would be appropriate for a school-age child. These responses are most characteristic of adolescents who have the most difficulty coping with death. Young children often feel guilty and responsible for a sibling's death, or may view illness or injury as a punishment for their thoughts about the sibling. "Our child wants to go to the cemetery to be with his sister." "Our child asks many questions about what happened to the baby's body." "Our child is not sleeping, eating, or playing lately and we are worried." "Our child blames himself for the baby's death because he said he didn't want a baby brother or sister." 57 31 A nurse is preparing a room for the admission of a client with sickle cell anemia who is in vasoocclusive crisis. Which type of equipment should the nurse place in the client's room? Wheelchairs are used to decrease energy expenditures; however, this is not the most important equipment needed at this time. It would be nice to have these available in the room, but these are not priority measures at this time. It would be nice to have these available in the room, but these are not priority measures. Exchange transfusion is an important part of the treatment for vaso- occlusive crisis. One of the main objectives when managing a sickle cell crisis is blood replacement to treat anemia and hydration to reduce the viscosity of the sickled blood. Wheelchair with adjustable leg rests A radio and age-appropriate reading materials Extra blankets and pillows Blood transfusion equipment 32 An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed in skeletaltraction. Which of the following nursing interventions is the most appropriate? Weights should hang freely to promote the forward force of traction. High-fat meals are not recommended. When a client is immobile, a high-fiber diet may be recommended to keep stools soft and prevent complications. The pulses on the side that are in traction are compared to the pulses on the contralateral side to assure that circulation in the affected side is not compromised. Color of the skin and nailbeds can also be assessed to observe for any neurovascular changes. The child's position should be changed at least every 2 hr to relieve frictional pressure on the bed and minimize skin breakdown. Passive, active, or active-with resistance exercises of the uninvolved extremities and joints should be performed to maintain strength and range of motion. Dependent upon the type of traction, varying degrees of position changes can be made without interfering with the traction. Position the weights securely against the foot of the bed. Provide small, frequent, high-fat meals to the child. Compare pulses on affected site to contralateral side. Provide diversional activities to minimize the child's movement. 33 A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of the following is the most serious clinical manifestations for which the nurse should monitor? 60 37 A nurse is caring for a child with muscular dystrophy. Which of the following priority actions should the nurse include in the care of this child? Maintaining function of muscles is the goal of treatment for muscular dystrophy. Stretching, range-of-motion exercises, and strength and muscle training should be performed to help maintain function. Children who remain active can delay the eventual confinement in wheelchair for a great length of time. Duchenne muscular dystrophy occurs from mother-to-son transmission of the defective gene. It is inherited from an X-linked trait. Therefore, genetic counseling is an important aspect of supportive family care and it is recommended for the parents, female siblings, maternal aunts, and their female offspring. This is not the priority nursing action. Flu and pneumococcal vaccines are encouraged as well as the avoidance of persons with respiratory infections because children with muscular dystrophy are at an increased risk for respiratory infections. Incentive spirometer use and breathing exercises should be performed daily to increase and maintain vital lung capacity. Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of muscle groups. Recommend genetic counseling for parents, male siblings, and paternal uncles and their male offspring. Advise against flu and pneumococcal vaccines due to a compromised respiratory system. Have the child use an incentive spirometer and perform breathing exercises routinely. 38 A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention? Children with glomerulonephritis require frequent monitoring of vital signs, but oxygen saturation is not necessary. For children with hypertension and edema, moderate sodium and fluid restrictions may be instituted. Foods high in potassium are restricted during oliguric periods. Due to the edema present in the disease process, the child is weighed and fluid balances monitored daily to check the fluid balance. This is not the first priority in the child's care. Most children recover completely. However, health supervision following hospitalization should be continued weekly and then monthly for evaluation and urinalysis. Monitor the oxygen saturation every 4 hr. Teach the parents dietary restrictions regarding protein. Weigh the child daily and record intake and output. 61 Counsel the parents about the need for follow-up. 39 A nurse is performing a routine physical examination on an adolescent client who asks, "Why do I have to use a condom if my girlfriend is on the pill? I thought the pill was enough protection against pregnancy." Which of the following is the most appropriate response by the nurse? Using two forms of birth control may be effective against pregnancy, but this response does not explain why one form must be a condom. Having both partners share responsibility for birth control is a positive situation, but this is not the reason the client should use a condom along with birth control pills. When used correctly, contraceptives are as effective in adolescents as in adults. Condoms are the only birth control method that protect against sexually transmitted diseases. "You need to use two forms of birth control so if one fails you have a second form of protection against pregnancy." "Using a condom allows you to share the responsibility for birth control." "Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form of contraception is needed." "Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually transmitted diseases." 40 A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the client's diagnosis, which of the following nursing actions is appropriate? HIV/AIDS is transmitted through blood and body fluids. The precautions necessary for blood and body fluid transmission are standard precautions. The client and the client's family should be educated regarding the transmission of infectious disease. Basic information about standard precautions should be presented in a manner that is age-appropriate and considers educational levels for the client and the client's family. The combination of hot water and detergents used in hospital dishwashers is sufficient to decontaminate dishes, glasses and cups, and eating utensils. Disposable dishes are not necessary. Airborne precautions require a negative pressure room. Tuberculosis, not HIV, is a disease that would require this precaution. Visitors do not need to wear either a gown or mask. A mask and gown are required during procedures and client care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions to provide protection from contact transmission of pathogenic organisms. Contribute to planning client education on standard precautions in age-appropriate manner. 62 Contact the dietary department to request foods be delivered on disposable dishes. Prepare for infection control in a negative pressure room for this client. Instruct visitors to wear gowns and masks when entering the client's room. 41 A nurse is reinforcing home care instructions with the parents of a 5-year-old child who has acute bronchitis. In order to prevent the transmission of the virus, which of the following should the nurse include in the instructions? Acute bronchitis is generally caused by a virus. Transmission is via direct contact; therefore, isolation is not required. Careful handwashing is important when caring for children with respiratory infections. They should be taught to use a tissue to cover their nose and mouth when they cough or sneeze and to wash their hands. Bronchitis is transmitted via articles contaminated with nasopharyngeal secretions. The virus will not live if dishes are washed properly. The combination of hot water and detergent is sufficient to decontaminate dishes, glasses, cups, and eating utensils. Clients wear masks when they are immunocompromised and a health care professional is trying to prevent the client from acquiring a secondary infection. A client with bronchitis is not considered immunocompromised. Isolate the child in a bedroom separated from the rest of the family. Teach the child to wash his hands after coughing secretions into a tissue. Serve food to the child on disposable dishes with plastic utensils. Have the child wear a mask whenever leaving the bedroom. 42 A nurse is monitoring a 6-month-old infant who is diagnosed with pneumonia. The nurse observes an absence of respirations and peripheral cyanosis. After determining unresponsiveness, which of the following is the next nursing action? This should be done after establishing an open airway. This is not the next nursing action. Following cardiopulmonary resuscitation (CPR) techniques, the nurse should determine unresponsiveness and reposition the infant to dislodge an obstruction or open the airway. For infants, help is called after 1 min of CPR. Look, listen, and feel for normal breathing. Give two rescue breaths. 65 Role playing is best when it involves the child and enables the child to handle equipment. This option has the nurse’s role playing with passive involvement of the child. Stories can be helpful to introduce the topic; however, this does not diminish the anxiety of seeing the equipment for the first time. Movies may scare a preschool child, especially if the child in the Movie cries during the procedure. Allowing the child to see, hold, and collect the supplies familiarizes the child with the frightening aspects of the procedure. Instruction can be based on the child's questions in a nonthreatening environment. The child can gain an understanding of the procedure by pretending to start an IV on a doll. Role play with another nurse the technique of IV placement and how the medication is infused. Read a story that explains the basics of how IVs are placed. Watch a movie narrated by nurses and children about IV placement. Explain the basic procedure and give the child IV supplies to play with, minus the needle. 48 A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect? Physical neglect involves the deprivation of necessities such as clothing, food, shelter, supervision, medical care, and education. Lack of parental education is not correlated with physical neglect. Socioeconomic group is not a factor in child neglect. If the child is clean, faded clothing with large shoes may be a sign of financial difficulties and not a sign of physical neglect. Lack of required immunizations Parental lack of education Lower socioeconomic group Faded clothing with large shoes 49 A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the following instructions is important to communicate to the nursing assistant? Toddlers are able to undress themselves, but do not have the fine motor development skills required for dressing. Allowing the child to feed himself provides opportunities for autonomy and motor skill development. Toddlers view everything in relation to self only and are involved 66 in parallel play. One way of dealing with negativism is to decrease opportunities for "no" answers. Have the toddler dress himself. Offer the toddler finger foods for snacks. Provide opportunities to share toys with others. Ask the child simple yes or no questions. 50 A nurse is caring for a 3-year-old child with strabismus. Which of the following actions should the nurse advise the parents to implement to help prevent amblyopia? Biconcave lenses are used to correct myopia. While trauma should be avoided to prevent eye damage, this is not an implementation to prevent amblyopia (impairment of vision or blindness) from strabismus. Strabismus, or cross eye, is when one eye deviates from the point of fixation. If the misalignment is constant, the weak eye becomes lazy and the brain eventually suppresses the image. If not corrected by the age of 4 to 6 years, blindness from disuse or amblyopia may result. Treatment includes covering the strong eye to strengthen the muscles in the weak eye. Dry eyes are not a manifestation of strabismus. Wear corrective biconcave lenses. Prevent trauma to the eyes. Patch the strong eye. Instill artificial tears. 51 A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority? Maintaining the infant's airway is of the highest priority. A child who is vomiting should be positioned on the side or in a semi-reclining position to prevent aspiration. Administration of fluids and electrolytes is important to prevent or correct dehydration and electrolyte imbalances, but is not of the highest priority. Antiemetic medications are administered as prescribed if necessary. This is not the first priority. Of major importance is avoiding ketosis. A dietary intake high in carbohydrates spares the body protein and avoids ketosis which can result from exhaustion of the glycogen stores. This is not the highest priority. Place the infant in a side or semi-reclined position. 67 Administer oral rehydration and electrolyte therapy. Administer antiemetic medications as prescribed. Maintain a high-carbohydrate intake to prevent ketosis. 52 A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in the diaper area and inner thighs. Which of the following statements by the parent indicates a correct understanding of this teaching Hair dryers can burn the skin and thus are not recommended. Powder should not be used. It tends to cake when the skin is wet, and there is also the danger of inhalation. Applying a skin cream barrier is much more effective. Rubber pants should not be used because they do not allow air to circulate. Thus, they promote skin irritation and breakdown. Exposing the skin allows it to air dry completely which helps prevent breakdown. "I can use a hair dryer on the reddened skin to help with the drying." "I can use powder after diaper changes to absorb excess moisture." "I can use cloth diapers with rubber outer pants until the rash clears." "I can keep the diaper off to expose the skin to air." 53 A 6-year-old child is brought to the emergency department after falling down the outdoor steps. The parent's account of the incident appears different than the neighbor's account of the incident. Upon questioning the child, the nurse should recognize which of the following as usual pattern of behavior exhibited by an abused child? The child would answer questions but would not contradict the parent's story. The typical reaction of the child is to repeat the same story as the parent. Children rarely betray the parent even when the parent is abusive. The child will even defend the parent. While children have creative imaginations, they do not make up stories in this scenario. Stress of the situation and the fear of losing what security they have with the parent keeps children who have been abused clinging to the parent's story. Children are afraid of losing the parent, so they do not implicate the parent in the abusive behavior. The child refuses to answer questions. The child repeats the same story as the parent. The child will fabricate an obviously false story. 70 Provide a low-calorie, high carbohydrate diet is incorrect. Clients who have suffered burns should have a high-protein, high-calorie diet. This helps to avoid protein breakdown as the body's metabolism increases after a burn injury. Monitor urinary output is correct. Urinary output helps to determine the adequacy of fluid resuscitation. Urine output and specific gravity help to establish adequate hydration and guide the rate of fluid administration. Administer morphine subcutaneously for pain is incorrect. Morphine sulfate is the preferred medication for severe burn injuries. It is administered continuously by IV infusion. The unstable circulatory status, edema, and tissue damage make intramuscular and subcutaneous injections contraindicated in burn injuries. Monitor level of consciousness is correct. Symptoms of confusion or seizures can result from alterations in the electrolyte balance. Disorientation is one of the first signs of sepsis or may indicate inadequate hydration. Maintain intravenous fluids is correct. Fluid shifts that occur after a burn injury make intravenous fluids very important. Intravenous fluid therapy compensates for loss of water and sodium, reestablishes electrolyte balance, and corrects acidosis. IV therapy restores circulating volume, provides sufficient perfusion, and improves renal function. Document vital signs is correct. Management of pulmonary and cardiovascular status is a priority, especially in the acute phase of burn injury treatment. The respiratory system is monitored for burn involvement and if suspected or evident, then 100% oxygen is administered. An endotracheal tube may need to be inserted to maintain the airway. Blood gas values including carbon monoxide levels are obtained. Heart rate helps to determine the adequacy of fluid resuscitation. Provide a low-calorie, high carbohydrate diet is incorrect. Clients who have suffered burns should have a high-protein, high-calorie diet. This helps to avoid protein breakdown as the body's metabolism increases after a burn injury. Monitor urinary output is correct. Urinary output helps to determine the adequacy of fluid resuscitation. Urine output and specific gravity help to establish adequate hydration and guide the rate of fluid administration. Administer morphine subcutaneously for pain is incorrect. Morphine sulfate is the preferred medication for severe burn injuries. It is administered continuously by IV infusion. The unstable circulatory status, edema, and tissue damage make intramuscular and subcutaneous injections contraindicated in burn injuries. Monitor level of consciousness. 71 Maintain intravenous fluids. Document vital signs. Provide a low-calorie, high-carbohydrate diet. Monitor urinary output. Administer morphine subcutaneously for pain. 58 A nurse is caring for a 7-month-old infant with acute bronchiolitis. The infant has a persistent, dry, hacking cough that worsens at night, tachypnea, and weakness. Which of the following actions should the nurse implement? Cough suppressants may be useful to allow rest but can interfere with clearance of secretions. They have not proven to be of benefit for this condition. Bronchiolitis is caused by a virus and is transmitted via direct contact. Therefore, contact precautions are required rather than droplet precautions. Antibodies and corticosteroids are not effective in uncomplicated bronchiolitis. Fluids by mouth may be contraindicated to prevent aspiration if the child has tachypnea, weakness, and fatigue. Therefore, IV fluids are preferred to maintain hydration and dilute secretions. Administer prescribed cough suppressants as needed. Place the child on droplet precautions. Administer antibiotics and corticosteroids as prescribed. Provide intravenous fluids as prescribed. 59 A nurse is caring for an infant with hypospadias. Which of the following is an expected finding? This defect describes epispadias, a condition in which the meatal/urethral opening is on the dorsal/back surface of the penis. With hypospadias, the urethral opening can be anywhere on the underside/ventral surface of the penile shaft or the perineum. Fluid in the scrotal sac is referred to as hydrocele. testes that are not palpable within the scrotal sac are an indication of cryptorchidism. This is a failure of one or both testes to descend through the inguinal canal. The meatal opening is on the dorsal surface of the penis. The urethral opening is on the underside of the penis. 72 Fluid is present in the scrotal sac containing the testes. The testes are not palpable within the scrotal sac. 60 A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI). The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of the following statements made by the parent indicates a correct understanding of the manifestations of a UTI? A child who has frequent urination and exhibits strong-smelling urine should be evaluated for a UTI. These are signs of glomerulonephritis, not UTI. These symptoms are seen in acute renal failure and are not signs of a UTI. Hematuria, not abdominal pain, is a sign of a UTI. "I should look for more frequent urination and strong-smelling urine." "My child would have tea-colored urine and puffiness around the eyes." "I should observe for episodes of nausea and less frequent urination." "My child would have pale-colored urine and abdominal tenderness and pain." 75 Correct: The first nursing priority is the implementation of antibiotic therapy, which prohibits the microbial damage to the neurologic system through the cerebral spinal fluid. Bacterial meningitis has a high rate of infant morbidity (illness) or mortality (death). Immediate treatment with antibiotics can prevent: death, deafness, reduced cognitive ability, attention deficit-hyperactive disorder, seizures and various other complications. Initiate cardiorespiratory monitoring. Initiate intravenous fluids. Observe respiratory isolation. Administer antibiotic therapy. 4 The dosage of a pediatric medication is 120mg/kg/day to be give t.i.d. The patient weighs 12 pounds. What is the correct dose for the nurse to administer? Incorrect: The dose of 120 mg is half the indicated dose. The erred dosage represents a failure to divide the total daily dose by the number of individual dosages required per day. The failure to use the weight in the calculation is evident. Incorrect: The dosage of 480 mg is an excessive dose for the child. The calculation error is likely a failure to convert pounds to kilograms. Correct: The patient weighs twelve pounds. This weight converts to kilograms by dividing 12 by 2.2 (1 kg. = 2.2 lb.). In this example, the child's weight converts to 5.4 kg. The daily dose of 120 mg is given t.i.d: each individual dose is 40 mg/kg. Then multiply the weight in kilograms by the individual dose (40mg). The individual dose is 218 mg. Incorrect: The dose of 650 mg is too large of a dose. The weight of the child when converting from pounds to kilograms is 5.45 kg. The dose is ordered to be given t.i.d.. Therefore, the daily dose of 120 mg/kg/day is divided by 3 to yield an individual dose of 40 mg/kg/dose. The error is this dosage was likely a failure to divide the total daily dose by the number of doses required per day. 120 mg 480 mg 218 mg 651 mg 76 5 In a child diagnosed with Tetralogy of Fallot, which of the following is a compensatory mechanism to decrease venous return to the heart? Correct: Squatting is a compensatory mechanism that decreases venous return (deoxygenated blood) to the heart. The clinical sign is commonly seen in young children with Tetralogy of Fallot (a type of cyanotic heart disease). The signs associated with cyanotic heart disease include hypoxia, poor growth, low tolerance for physical exertion, cardiomegaly, murmur and acute, intermittent blue spells that occur after crying or feeding (tet spells). Incorrect: Clubbing is found in children with chronic respiratory disease and cyanotic heart disease. However, this finding is rare in young children. Incorrect: Shortness of breath, retractions and increased respiratory effort occur with lung dysfunction. Generally, the child with impaired oxygenation due to a cardiac lesion does not exhibit signs of respiratory distress. Incorrect: Polycythemia is common in children with hypoxia due to respiratory or cardiac dysfunction. This compensatory mechanism increases the oxygen-. carrying capacity in the body. The effect is not related to the venous return of unoxygenated blood to the heart. Squatting Clubbing Shortness of breath Polycythemia 6 A 1-year-old receives routine health maintenance care at the pediatric clinic. The child receives an MMR immunization. The mother asks the nurse, "When will my child get the next dose of MMR vaccine?" Which is the correct response by the nurse? Incorrect: The DPT vaccine is routinely given in six months. Incorrect: An additional dose of MMR vaccine is needed in the middle school years to maintain full immunity from the diseases. Incorrect: The first dose of Hepatitis B vaccine (HBV) is given in the hospital prior to discharge home. A follow-up HBV is given in 1-2 months and followed up in 6-12 months following the second does. The schedule does not coordinate with the routine immunization schedule for MMR. 77 Correct: A second MMR, often called a booster, will be needed when the child enters middle school at age eleven or twelve years of age. In six months with the next DPT No further vaccination needed With the Hepatitis B series After the child is 10 years of age 7 Which is a major difference in the clinical manifestation of adolescents with anorexia nervosa compared to bulimia? Incorrect: Binge eating is a common manifestation of both disorders. Incorrect: Purging can be associated with both disorders. Correct: The major difference between adolescents with anorexia nervosa and adolescents with bulimia is body image distortion. Clients with anorexia see themselves as being overweight no matter how underweight they become. Clients with bulimia see their weight realistically but have psychological problems that manifest in an eating disorder. Incorrect: Decreased self-esteem is often a catalyst of both disorders. Binge eating Purging Body image distortion Decreased self esteem 8 Which is the most common factor associated with non-organic failure to thrive? Incorrect: A cool, drafty sleeping area is not a comfortable environment for sleep, but is unrelated as a cause of failure to thrive. Correct: The most significant factor associated with non-organic failure to thrive is typically a disturbance in the mother/child relationship. A situation involving dysfunctional family relationships is often complex; characterized by marital discord, economic pressures, and parental immaturity with a low stress tolerance. 80 In the classroom at the end of the day Nurse's office before school Physical education class 12 The health care provider orders 60% oxygen to be administered with a partial rebreather mask and bag reservoir. Which error regarding the oxygen delivery system requires correction? Incorrect: Moisture collecting in the mask is the result of humidification of the air. Oxygen can be very drying to the tissue and alveoli; damage can result to the airways without humidification. Incorrect: To optimize the delivery of oxygen via mask, a snug head strap is necessary. Incorrect: The mask covering the nose and mouth is a correct application of the mask. Correct: The reservoir bag on the non-rebreather mask should remain partially filled during inspiration to provide positive end expiratory pressure (PEEP). If the bag collapses the equipment may be faulty. Moisture collects inside the mask The strap around the head is snug The mask covers the nose and mouth The reservoir bag collapses during inspiration 13 A toddler is admitted to the hospital for treatment of acute gastroenteritis and dehydration. The mother states that she must go home to make arrangements for the care of her other children. To reduce the child's separation anxiety, which nursing intervention is most appropriate? Incorrect: Placing the child in the crib may make the child feel more alone and afraid. At this developmental stage, the child is not likely to be comfortable enough with the surroundings to adjust and begin to play. Correct: Anxiety is the child's predominant emotion with the separation from a parent. Activities that calm and comfort the child are appropriate. Often a toddler will fall asleep in the nurse's arms due to the stress of a parent's leaving the child alone in the hospital. Incorrect: The video may serve as a distraction, but does not provide the security of human contact. 81 Incorrect: The nurse's station may allow an opportunity for social contact. Many toddlers may be overwhelmed or frightened by the activity at this central location. Place the child in the crib with toys. Rock the child in a rocking chair. Turn on an age-appropriate video. Take the child to the nurse's station. 14 Which technique is most appropriate when assessing the circulation of a child's leg in traction? Incorrect: The movement of the toes is a neurological assessment and does not relate to circulation. Correct: The best way to assess circulation is to palpate the dorsalis pedal pulse located on the top of the foot. If a peripheral pulse is not palpable, a Doppler may be necessary to ascertain loss of circulation and pulse. Incorrect: Assessing pain sensation in the lower extremities is a neurological assessment and does not relate to circulation. Incorrect: Range of motion to the affected area is usually contraindicated while in traction. Determine if the child can wiggle the toes. Palpate the dorsalis pedis artery. Assess for pain sensation in the lower extremity. Perform range of motion in the lower extremity. 15 Initially, which solid food is generally recommended for an infant's diet? Correct: Rice cereal is bland, easily digested and fortified with iron. Rice cereal is the first food introduced into the diet at approximately six months. 82 Incorrect: Strained vegetables are introduced after the infant tolerates rice cereal. The order that various foods are initiated is controversial and dependent on regional, generational, cultural and personal factors. Incorrect: Strained fruits are introduced generally after the infant tolerates strained vegetables. Incorrect: Meats are introduced between 8-10 months of age. Infant meats are generally denser in texture and less preferred by many infants. The coordination of the muscles of the tongue and pharynx must be more developed for the introduction of solid meat. Infant rice cereal Strained vegetables Strained fruits Infant meats 16 A boy diagnosed with hemophilia falls while roller-blading and injures his knee. The nurse is most likely to assess which physical finding? Correct: Hemophilia is a group of bleeding disorders in which there is a deficiency of one of the clotting factors. After a child sustains a traumatic injury to a joint, hemarthrosis is likely to result. Incorrect: Thrombocytopenia, is a decreased number of platelets in the circulating blood, and is not related to hemophilia. Incorrect: Petechiae are pinpoint non-raised, purplish spots on the skin, which are characteristic of low platelets. Incorrect: Neutropenia, which is the diminished number of neutrophils, is not associated with hemophilia. Hemarthrosis Thrombocytopenia Petechiae Neutropenia 85 1300 1500 21 The nurse evaluates the effectiveness of care for the school-aged child with juvenile rheumatoid arthritis (JRA). Which clinical outcome does the nurse expect the child to demonstrate after nursing care interventions are implemented? Incorrect: JRA is treated with non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, aspirin, and naproxen, to reduce inflammation to the joints. Slower-acting antirheumatic drugs may be added. Cytotoxic drugs are reserved for the child with severe, debilitating disease. Antibiotics are not used for JRA. Correct: The nurse observes the movements of the child and uses pain assessment tools to determine the intensity of pain. Nonpharmacologic modalities and anti-inflammatory and analgesic medication are provided to promote comfort and relieve pain associated with JRA. By modifying pain perception, joint mobility is likely to improve with reduced discomfort. Incorrect: Children are encouraged to maximize their efforts for self-care and activities of daily living. Exercise enhances the mobility and strength of the supporting muscles, which is necessary in pain prevention. However, overexertion should be avoided. Incorrect: Children with JRA, like many with chronic illness or disability, develop personality traits including: manipulativeness, hostility, and passive aggressiveness. Although it is the goal for care of the family to promote an understanding of the child's disease and altered lifestyle and have compassion for the situation, it is important that family members do not enable the negative behaviors to persist. Efforts need to be made to intervene early and prevent permanent ineffective coping techniques. The symptoms will subside with use of antibiotics. The child is able to move with minimal or no discomfort. The child limits his own physical activity to prevent pain. The family copes with the child's manipulative behaviors. 22 The nurse providing care to the child with pediculosis capitus (head lice) educates the family about the condition, transmission, and treatment. Which condition is necessary for survival of the louse on the host? 86 Correct: Survival of the louse is dependent upon blood that is extracted from the host. Incorrect: The louse feeds on the blood of the human host. Warmth is not necessary for survival. Incorrect: The louse feeds on the blood of the human host. Moisture is not necessary for survival. Incorrect: The louse feeds on the blood of the human host. Mucous is not necessary for survival. Blood Warmth Moisture Mucous 23 An adolescent with Type I diabetes mellitus asks her mother for permission to go with friends to get pizza and ice cream. Which response by the adolescent's mother indicates that previous nursing instruction has been effective? Incorrect: It is not necessary to reinforce to the adolescent that he/she is unable to eat similar to the friends. Peer groups and being accepted are very important at this age. The adolescent who can manage the insulin needs in accordance with the diet is allowed to have a variety of foods. Incorrect: It is not realistic or therapeutic to expect the friends to know the diabetic diet. This type of expectation may alienate the child from the peer group. The adolescent typically values the similarity to the peer group. Incorrect: By avoiding the situation, the adolescent does not directly deal with the underlying task of adapting the chronic illness into the lifestyle. An important part of developing relationships among adolescents is spending leisure time together. The child alienates him or herself and suppresses feelings of anger towards self, others and/or the disease. Correct: The standard diabetic diet and appropriate nutritional education are flexible and incorporates many preferred foods at various times. The dose of insulin will need to be adjusted for this altered schedule, type and amount of food. Close glucose monitoring is very important to the safety of the diabetic child whose metabolic needs are variable. "It is important for you to spend time with friends but you cannot eat what they are eating." "Your friends need to learn that there are certain foods that you cannot have. They will understand that you can't go with them." "You must stay away from those foods. It is easier for you to avoid the situation. You can go with your friends another time." 87 "It is important for you to spend time with your friends. I will help you select your food and determine your next insulin dose." 24 When obtaining a health history, which significant event may precede a diagnosis of rheumatic fever? Incorrect: Chickenpox is caused by varicella virus. Rheumatic fever is a complication of group A beta hemolytic streptococcal pharyngitis. Correct: There is evidence that rheumatic feverish associated with group A beta hemolytic streptococci, which is a common cause of pharyngitis. Incorrect: The presence of a heart murmur is not reason enough to diagnose rheumatic fever. Rheumatic fever is associated with streptococcal infections. Incorrect: Vomiting and diarrhea are frequently caused by intestinal viruses, not bacteria. The primary symptoms of group A beta hemolytic streptococcal pharyngitis include: fever, malaise, dysphagia, lymphadenopathy and occasionally diarrhea in the young child. Rheumatic fever is a complication of “strep throat” that can cause cardiac damage. Exposure to chickenpox Recent severe sore throat Presence of a heart murmur Vomiting and diarrhea 25 Which intervention is most appropriate when providing nursing care for the child diagnosed with Duchenne's muscular dystrophy? Incorrect: Limitation of physical activity may accelerate the process of muscular deterioration and atrophy. Incorrect: Increased weight gain becomes more likely as the activity level diminishes. The care of the child with a progressive, incapacitating disease becomes increasingly more demanding for the caregivers at home. As a loss of mobility and independence occurs, the child will require more lifting, dressing and physical care. Excessive weight would aggravate the situation. Correct: The most important way for the nurse to impact the family of the child with Duchenne's muscular dystrophy is to assist the child and family in coping with the progressive, incapacitating and incurable disease. As muscular weakness progresses, 90 29 During the acute phase of glomerulonephritis in a child, which intervention is the most appropriate? Incorrect: Although the child with acute glomerulonephritis is more susceptible to infection, protective isolation procedures are not indicated. Careful handwashing and avoidance of known or likely exposure to infectious organisms is reasonable and prudent. Incorrect: During the oliguric phase of glomerulonephritis, the potassium intake should be limited. The risk for hyperkalemia is increased if a high potassium intake accompanies decreased urinary output and excretion of potassium. Incorrect: Bedrest is often maintained in the acute phase. Children have malaise and fatigue with glomerulonephritis and usually restrict their own activities. Although rest and sleep are important, the most important intervention is focused on the prevention of serious complications, such as malignant hypertension. Correct: Neurologic complications, such as seizures and diminished level of consciousness may occur because of severe hypertension associated with acute glomerulonephritis. The child with edema, hypertension and gross hematuria may be subject to neurologic complications. Observe protective isolation procedures. Encourage increased potassium intake. Encourage bedrest with appropriate diversional activity. Assess the child for signs of neurologic complications. 30 An 18-year-old female diagnosed with systemic lupus erythematosus (SLE) comes to the rheumatology clinic for a follow-up visit. The nurse assesses the client's skin and reviews the client's BUN and creatinine levels. Which is the rationale for the nurse's actions? Correct: SLE is a chronic inflammatory disease characterized by injury to the skin, joints, kidneys, nervous system and mucous membranes. Clients often seek medical help for relief of fever, weight loss, joint pain, butterfly rash, pleural effusion and nephritis. Because of the kidney damage, the blood pressure will rise and protein in the urine may be evident. Edema results. Incorrect: Kidney damage is common, but does not result in dehydration or dry skin. 91 Incorrect: The characteristic rash in SLE is on the face, not generalized over the body, and is in the shape of a butterfly. Incorrect: Urinary frequency is not a characteristic of SLE. Instead hematuria and decreased urine output are common. A "butterfly rash" and kidney damage are common characteristics of the disease. The client is prone to dry, scaly skin and dehydration related to kidney dysfunction. The generalized rash may lead to a secondary infection affecting the kidneys. The disease process is complicated by urinary frequency and a papular rash. 31 At an unscheduled clinic appointment, the mother of a 9-month-old states that she is concerned about her baby's small size and frequent crying. The mother has limited support systems and poor role modeling for parenthood from her own childhood. Which initial physical assessment data is most important for the nurse to obtain at this time? Incorrect: The measurement of head and chest circumference can provide data indicating the presence of hydrocephalus, microcephaly or neurological defects. Although these growth parameters also indicate the patterns of growth, the height and weight are more specific measures of overall growth. Incorrect: Heart rate and breath sounds are important measures for the physical assessment of the cardiorespiratory status but do not indicate growth patterns. Correct: Excessive crying may indicate a wide variety of physical or emotional problems in infancy. The nurse who suspects that the infant is failing to thrive in the home environment first obtains the data regarding the infant's pattern of growth: the height and weight. Incorrect: The suck reflex, present at birth, is vital for infant nutrition. By nine months of age, however, the child should be eating solid foods, chewing soft foods and teething. The assessment for presence of the suck reflex is most appropriate during the newborn assessment. Chest and head circumference Heart rate and breathe sounds Height and weight Sucking reflex 92 32 Which information regarding suspected episodes of child abuse should the nurse include in the documentation? Incorrect: Summative statements regarding the events of potential child maltreatment or sexual abuse are inappropriate. Direct quotes from interviewees are recommended to reduce bias and premature judgment. Correct: The documentation of events related to potential child abuse needs to be an objective, factual and concise. Direct quotations from interviewees are recommended to reduce personal bias, interpretation or judgment. Incorrect: Generalizations regarding the nature of actions leading to harm in a child are inappropriate. Clear, concise, and concrete information is absolutely necessary for the documentation of the events in question. Incorrect: Interpretative statements do not have an appropriate role in the delivery of care to the child with suspected maltreatment or sexual abuse. When allegations are made regarding the actions leading to harm to a child, clear, concise and factual information needs to be documented. Summative statements Exact quotes regarding the events Generalized description of events Statements related to causative factors 33 A toddler is diagnosed with impetigo and the nurse gives the toddler's mother instructions about skin care. Which statement by the mother indicates a need for further education? Incorrect: The transmission of impetigo occurs from direct contact with infected skin surfaces. The disease is highly contagious. Incorrect: Impetigo contagious is highly communicable in the toddler and preschool child. The skin is colonized with staphylococcal organisms that cause impetigo and therefore, toddlers and preschoolers are susceptible to bacterial infections from their own skin. Correct: Impetigo is a staphylococcal infection that is highly contagious. The impetigo lesions should be cleaned three to four times a day with Burrow's solution 1:20 to remove the crusts. Usually, the application of a topical bactericidal ointment (Bactroban) follows the wound debridement. With proper wound care, lesions are not likely to scar unless a secondary infection occurs. 95 Incorrect: An air embolism would present with symptoms of difficulty breathing, a sharp pain in the chest and apprehension. Incorrect: A hemolytic reaction may present with symptoms of chills, fever, nausea/vomiting, headache, pain in the chest, not dyspnea, and moist cough. An allergic reaction Fluid overload An air embolism A hemolytic reaction 38 The nurse plans the preoperative care of the infant with pyloric stenosis. In feeding the infant, which measure should be implemented until surgery? Incorrect: An increase in the frequency and amount of the feedings will increase the volume of the stomach, which is already having difficulty emptying, resulting in overload within the stomach. Projectile vomiting is a common symptom. Incorrect: Burping any infant is important. The infant with pyloric stenosis is not burped any more frequently than any other infant. Care is taken that the infant is handled gently during the burping. Incorrect: The Breck feeder is used for infants with cleft lip and palate. Correct: Pyloric stenosis is a narrowing of the pyloric sphincter at the outlet of the stomach. The infant should be allowed to rest after the feeding. Handling the infant should be kept to a minimum so the feeding can advance down the digestive tract. Increase the frequency of the feedings. Burp the infant between feedings. Feed the infant with a Breck feeder. Let the infant rest after the feeding. 39 When providing instructions to a day care provider about the transmission of chickenpox, which statement by the day-care worker reflects a need for further education about the infectious phase of this disease? Incorrect: Varicella virus is transmitted through the respiratory route in the droplet form. 96 Incorrect: Varicella virus is transmitted through direct or indirect contact. Correct: Chickenpox is a highly contagious disease caused by a primary infection with varicella-zoster virus. The characteristic feature is the generalized, vesicular rash that itches. The mode of transmission is direct contact with persons infected with the varicella and herpes zoster viruses. Respiratory spread by droplet also occurs. The disease is most contagious in the incubation period prior to or including the time of onset of prodromal symptoms and the first crop of the rash. The lesion dries and the crust falls off within 5 to 20 days. By the time the lesions scab over, children are no longer infectious and may return to the daycare setting. Seizures are not associated with chickenpox. Incorrect: Varicella lesions with drainage are contagious; the child should remain at home until all vesicles have dried and crusted. Immunosuppresses persons should not be exposed to the virus. "Chickenpox is spread through the respiratory tract." "Chickenpox is transmitted by direct contact." "When the rash first appears, we should watch for seizures." "Children that have seeping pox should remain at home." 40 Digoxin (Lanoxin) is used in the treatment of a client diagnosed with a congenital heart defect. Which is the mechanism of action? Incorrect: The mechanism of action for digoxin is increased cardiac contractility. Nitroglycerine, not digoxin, is an example of a cardiac medication that is used primarily for the effect of vasodilation of the coronary arteries. Correct: Digoxin is used to increase the contractility of the heart and improve the cardiac output. By increasing the effectiveness of the heart's pumping action, the blood supply to the body is improved. The increased tissue perfusion leads to improved oxygen delivery to the organ sites. Incorrect: Digoxin is primarily used to increase the cardiac output by improving the contractility of the heart. Incorrect: A diuretic is often used for congestive heart failure to reduce systemic overload associated with congenital heart defects. Dilates the coronary arteries Improves contractility of the heart 97 Reduces venous return to the heart Decreases systemic overload 41 The nurse provides care for the child diagnosed with glomerulonephritis and collects a urine sample for urinalysis. Which urine color suggests the presence of red blood cells? Correct: The presence of blood in the urine gives the urine a smoky color. Incorrect: A cloudy appearance is commonly associated with the presence of white blood cells. Incorrect: Bright orange urine occurs as a result of the administration of phenazopyridine hydrochloride (Pyridium). This medication reduces the symptomatic relief or urinary burning, itching, frequency and urgency with urinary tract infection or following urologic procedures. This medication stains clothing. Incorrect: Dark yellow urine is an indication of concentrated urine with a high specific gravity. Smoky Cloudy Bright orange Dark yellow 42 A 2-month-old baby is diagnosed with cystic fibrosis. Which statement most accurately defines this disorder? Incorrect: Cystic fibrosis is not a dominant disorder and does not lead to fatty deposits on the liver. Incorrect: Cystic fibrosis is not linked on a dominant gene and is not produced by the lungs. Incorrect: Structural changes of the heart are not produced by cystic fibrosis. Correct: Cystic fibrosis is a recessive disorder that is inherited from both parents. Cystic fibrosis is a disorder of the exocrine glands causing the glands to produce abnormally thick mucus secretions. The glands most affected are those in the pancreas, respiratory system and sweat glands.