G and D Flashcards
Which age group has the greatest potential to demonstrate regression when they are sick?
A. Infant
B. Toddler
C. Adolescent
D. Young Adult
Correct Answer: B. Toddler
Regression is most seen among toddlers and it can be caused by stressful situations such as hospitalization, the arrival of a new sibling, or starting a new school.
One of the participants attending a parenting class asks the teacher “What is the leading cause of death during the first month of life?
A. Bacterial sepsis
B. Respiratory distress of newborn
C. SIDS (Sudden Infant Death Syndrome)
D. Neonatal hemorrhage
Correct Answer: C. SIDS
According to the CDC, sudden infant death syndrome (SIDS) remains to be one of the leading causes of infant death. Around 1,300 infants died in 2018 due to this condition. SIDS is defined as the sudden and unexplained death of a baby younger than 1-year-old.
Which stage of development is most unstable and challenging regarding the development of personal identity?
A. Adolescence
B. Toddlerhood
C. Middle Childhood
D. Young adulthood
Correct Answer: A. Adolescence
Although it occurs throughout one’s lifetime, identity development is considered to be the primary psychosocial task of adolescence or as described by Erickson on identity versus identity confusion. Individuals in this stage start to integrate their values, abilities, inner drives, and past experiences into who they are as persons.
Which age group would have the most tendency towards eating disorders?
A. Adolescence
B. Toddlerhood
C. Preschool
D. Infancy
Correct Answer: A. Adolescence
The adolescent stage is the time where the body starts to change and with factors including exposure from media and peer pressure that provide them the perception of an ideal body image which would then affect their dietary behaviors leading to eating disorders.
When assessing an older adult., the nurse may expect an increase in:
A. Nail growth
B. Skin turgor
C. Urine residual
D. Nerve conduction velocity
Correct Answer: C. Urine residual
Older adults with other health conditions such as diabetes, enlarged prostate (men), or pelvic organ prolapse (women) may cause incomplete bladder emptying resulting in increased urine residual.
A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson’s psychosocial development theory, the nurse would instruct the mother to
A. Allow the newborn infant to signal a need
B. Anticipate all of the needs of the newborn infant
C. Avoid the newborn infant during the first 10 minutes of crying
D. Allow the infant to cry, once lessen, then attend to the infant
Correct Answer: A. Allow the newborn infant to signal a need.
If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. The primary way the caregiver can build trust with the baby is to respond when they try to communicate. Because babies can’t use words to express themselves, they use nonverbal strategies to communicate what they’re thinking and feeling at all times.
A mother of a three (3)-year-old tells a clinic nurse that the child is constantly rebelling and having temper tantrums. The nurse most appropriately tells the mother to:
A. Punish the child every time the child says “no”, to change the behavior
B. Allow the behavior because this is normal at this age period
C. Set limits on the child’s behavior
D. Ignore the child when this behavior occurs
Correct Answer: D. Ignore the child when this behaviour occurs.
The parents of a two (2)-year-old boy arrive at a hospital for a visit. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. The nurse interprets this behavior as indicating that:
A. The child is withdrawn
B. The child is self-centered
C. The child has adjusted to the hospitalized setting
D. This is a normal pattern
Correct Answer: D. This is a normal pattern.
The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of despair, the child may not approach them readily or may cling to a parent.
The mother of a three (3)-year-old is concerned because her child still is insisting on a bottle at nap time and bedtime. Which of the following is the most appropriate suggestion to the mother?
A. Do not allow the child to have the bottle
B. Allow the bottle during naps but not at bedtime
C. Allow the bottle if it contains juice
D. Allow the bottle if it contains water
Correct Answer: D. Allow the bottle if it contains water
It is recommended that parents should wean their children off the bottle at 15-18 months of age. But If a bottle is still attached to the child at 3 years of age during naptime or bedtime, it should contain only water to prevent the risk of dental caries.
A nurse is evaluating the developmental level of a two (2)-year-old. Which of the following does the nurse expect to observe in this child?
A. Uses a fork to eat
B. Uses a cup to drink
C. Uses a knife for cutting food
D. Pours own milk into a cup
Correct Answer: B. Uses a cup to drink
By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. Children can start learning how to use a cup without a lid when they are 9 months old. Most experts recommend introducing utensils between 10 and 12 months, as an almost-toddler starts to show signs that she’s interested. A spoon should be first on the child’s tray since it’s easier to use.
A clinic nurse assesses the communication patterns of a five (5)-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant:
A. Uses simple words such as “mama”
B. Uses monosyllabic babbling
C. Links syllables together
D. Coos when comforted
Correct Answer: B. Uses monosyllabic babbling.
Monosyllabic babbling occurs between 3 and 6 months of age. The infant starts to produce vowels and combines them with consonants, producing syllables (e.g., ba, da, la, ga). An infant should be babbling away by now, and those babbles might even be starting to sound like real words. Five-month-olds can begin to put consonant and vowel sounds together.
A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?
A. Endometritis
B. Endometriosis
C. Salpingitis
D. Pelvic thrombophlebitis
Correct Answer: A. Endometritis
Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region.
A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?
A. The ultrasound will help to locate the placenta.
B. The ultrasound identifies blood flow through the umbilical cord.
C. The test will determine where to insert the needle.
D. The ultrasound locates a pool of amniotic fluid.
Correct Answer: B. The ultrasound identifies blood flow through the umbilical cord.
Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?
A. Calcium gluconate
B. Protamine sulfate
C. Methylergonovine (Methergine)
D. Nitrofurantoin (Macrodantin)
Correct Answer: B. Protamine sulfate
Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?
A. Turn the neonate every 6 hours
B. Encourage the mother to discontinue breastfeeding.
C. Notify the physician if the skin becomes bronze in color.
D. Check the vital signs every 2 to 4 hours.
Correct Answer: D. Check the vital signs every 2 to 4 hours
While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?
A. Back
B. Abdomen
C. Fundus
D. Perineum
Correct Answer: D. Perineum
A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.
The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:
A. “Nausea and vomiting can be decreased if I eat a few crackers before rising.”
B. “If I start to leak colostrum, I should cleanse my nipples with soap and water.”
C. “If I have a vaginal discharge, I should wear nylon underwear.”
D. “Leg cramps can be alleviated if I put an ice pack on the area.”
Correct Answer: A. “Nausea and vomiting can be decreased if I eat a few crackers before arising”
Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.
Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?
A. Taking in
B. Letting go
C. Taking hold
D. Resolution
Correct Answer: C. Taking hold
Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?
A. Activity limited to bed rest.
B. Platelet infusion.
C. Immediate cesarean delivery.
D. Labor induction with oxytocin.
Correct Answer: A. Activity limited to bed rest
Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.
The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?
A. Feeding the neonate a maximum of 5 minutes per side on the first day.
B. Wearing a supportive brassiere with nipple shields.
C. Breastfeeding the neonate at frequent intervals.
D. Decreasing fluid intake for the first 24 to 48 hours.
Correct Answer: C. Breastfeeding the neonate at frequent intervals
Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?
A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex
Correct Answer: A. Startle reflex
The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.
A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:
A. Tailor sitting
B. Leg lifting
C. Shoulder circling
D. Squatting exercises
Correct Answer: A. Tailor sitting
Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.
Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?
A. Notify the neonate’s pediatrician immediately.
B. Check the diaper and circumcision again in 30 minutes.
C. Secure the diaper tightly to apply pressure on the site.
D. Apply gentle pressure to the site with a sterile gauze pad.
Correct Answer: D. Apply gentle pressure to the site with a sterile gauze pad
If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.
Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta?
A. Excessive vaginal bleeding
B. Rigid, board-like abdomen
C. Tetanic uterine contractions
D. Premature rupture of membranes
Correct Answer: B. Rigid, board-like abdomen
The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.
