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Kaplan NCLEX Review > Health Promotion And Maintenance > Flashcards

Health Promotion And Maintenance Flashcards

1
Q

Growth and development characteristics: 1 month

A

Head sags (neck muscles not strong enough)

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2
Q

Growth and development characteristics: 2 months

A
  • closure of posterior fontanelle
  • infant can turn from side to back
  • infant develops social smile
  • infant’s eye will begin to follow a moving object
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3
Q

Growth and development characteristics: 3 months

A
  • infant brings objects to mouth
  • infant can hold head erect, smile at mother, and laugh
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4
Q

Growth and development characteristics: 4 months

A
  • thumb apposition, drools
  • absent tonic neck reflex/moro reflex
  • pleasure in social contact
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5
Q

Growth and development characteristics: 5 months

A
  • birth weight doubled
  • infant takes objects presented to him/her
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6
Q

Growth and development characteristics: 6 months

A
  • weight gain 4 oz/week in second 6 months
  • begins teething
  • infant can turn from back to stomach
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7
Q

Growth and development characteristics: 7 months

A
  • sits for short periods
  • grasps toys with one hand
  • fear of stranger begins to appear
  • abrupt mood shifts
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8
Q

Growth and development characteristics: 8 months

A
  • anxiety with strangers
  • separation anxiety
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9
Q

Growth and development characteristics: 9 months

A
  • elevates self to sitting position
  • says “Dada”
  • responds to parental anger
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10
Q

Growth and development characteristics: 10 months

A
  • crawls well
  • pulls self to standing position
  • vocalize one or two words
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11
Q

Growth and development characteristics: 11 months

A

Infant can stand erect with support

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12
Q

Growth and development characteristics: 12 months

A
  • birth weight tripled
  • needs help while walking
  • sits from standing position
  • eat with fingers
  • may say words other than “mama” and “dada”
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13
Q

Age-appropriate toys for infants from birth to 2 months

A

Mobiles

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14
Q

Age-appropriate toys for infants 2-4 months

A

Rattles, cradle gyms

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15
Q

Age-appropriate toys for infants 4-6 months

A

Brightly colored toys to grasp

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16
Q

Age-appropriate toys for infants 6-9 months

A

Large toys with bright colors, movable parts, noise makers

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17
Q

Age-appropriate toys for infants 9-12 months

A

Books with large pictures, push pull toys, teddy bears

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18
Q

At what age is solid food typically introduced to infants?

A

4-6 months

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19
Q

Solid food introduction considerations

A
  • introduce one food at a time each 2-week period
  • introduce least allergenic foods first half of first year, and more allergenic foods last half of first year
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20
Q

Usual order to introduction of solid foods

A

Cereal, vegetables & fruits (non-citrus), potatoes, meats, eggs, orange juice*
NOTE: * indicates allergenic foods

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21
Q

Growth and development characteristics: 15 months

A
  • walks alone
  • throws objects
  • holds spoon
  • names commonplace objects
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22
Q

Growth and development characteristics: 18 months

A
  • anterior fontanelle closure
  • walks backward
  • climbs stairs
  • hold crayon and scribble
  • 10 word vocabulary
  • thumb sucking
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23
Q

Growth and development characteristics: 24 months

A
  • 300-word vocabulary
  • obeys easy commands
  • jumping
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24
Q

Growth and development characteristics: 30 months

A
  • walks on tiptoe
  • stands on one foot
  • sphincter control fully developed for toilet training
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25
Q

Age-appropriate toys for toddlers (12-36 months)

A
  • push-pull toys
  • stuffed animals
  • dolls
  • low rocking horse
    NOTE: avoid toys with small pieces to prevent airway obstruction; PARALLEL play develops at this age and these children often play through imitation
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26
Q

Growth and development characteristics: 3 years

A
  • copies a circle
  • decrease in tantrums
  • rides a tricycle
  • walks downstairs without assistance
  • undresses without help
  • 300-word vocabulary
  • may invent imaginary friend
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27
Q

Growth and development characteristics: 4 years

A
  • climbs and jumps wells
  • laces shoes
  • brushes teeth
  • 1,500-word vocabulary
  • skips and hops on one foot
  • can throw ball or object overhead
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28
Q

Growth and development characteristics: 5 years

A
  • runs well
  • jumps rope
  • dresses without help
  • 2,100-word vocabulary
  • tolerates increasing periods of separation from parents
  • beginning of COOPERATIVE play
  • learns how to tie shoes
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29
Q

Age-appropriate toys for preschool children (ages 36 months-6 years)

A
  • playground materials
  • housekeeping toys
  • coloring books
  • tricycle with helmet
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30
Q

Growth and development characteristics: 6 years

A
  • self centered, show off
  • Sensitive to criticism
  • begins losing temporary teeth
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31
Q

Growth and development characteristics: 7 years

A
  • participates in team games/sports
  • develops concept of time
  • plays with other children of same sex
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32
Q

Growth and development characteristics: 10-12 years

A
  • remainder of teeth (except wisdom) erupt
  • begins to develop interest in opposite sex
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33
Q

Play characteristics age 0-1 year

A

Holding toys

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34
Q

Play characteristics ages 1-7 years

A

Imitation

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35
Q

Play characteristics ages 8-12 years

A

Games and hobbies

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36
Q

Type of play exhibited throughout infancy

A

Solitary play

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37
Q

Type of play exhibited by toddlers

A

Parallel play

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38
Q

Type of play exhibited by preschoolers

A

Associative play

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39
Q

Type of play exhibited by school-age children

A

Cooperative play

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40
Q

Erikson’s trust v.mistrust stage of development

A
  • Age: birth-1 year
  • positive outcome: trusts self and others
  • negative outcome: withdrawn, isolated
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41
Q

Erikson’s autonomy v. Shame and doubt stage of development

A
  • Age: 1-3 years
  • positive outcome: exercises self control
  • negative outcome: defiant and negative
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42
Q

Erikson’s initiative v. Guilt stage of development

A
  • Age: 3-6 years
  • positive outcome: learns limits
  • negative outcome: fearful, pessimistic
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43
Q

Erikson’s industry v. Inferiority stage of development

A
  • Age: 6-12 years
  • positive outcome: sense of confidence
  • negative outcome: self doubt and feelings of inadequacy
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44
Q

Erikson’s identity v. Role diffusion stage of development

A
  • age: 12-20 years
  • positive outcome: coherent sense of self and plans for education, work, and future
  • negative outcome: lack of personal or vocational identity
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45
Q

Erikson’s intimacy v. Isolation stage of development

A
  • age: 20-35 years
  • positive outcome: intimate relationship
  • negative outcome: avoidance of intimacy
46
Q

Erikson’s generatively v. Stagnation stage of development

A
  • age: 35-65 years
  • positive outcome: creative and productive
  • negative outcome: self-centered
47
Q

Erikson’s integrity v. Despair stage of development

A
  • age: 65+
  • positive outcome: sees life as meaningful
  • negative outcome: fear of death and life lacking meaning
48
Q

Mild intellectual delay

A
  • IQ 55-70
  • slow to walk, feed self, and talk
  • may be able to learn reading and math for 3rd-6th grade level
49
Q

Moderate intellectual delay

A
  • IQ 40-55
  • delay in motor movement
  • able to perform some self-help activities
  • will respond to training
  • will NOT progress with reading or math skills
  • communication skills will be poor
50
Q

Severe intellectual delay

A
  • IQ 24-40
  • marked delay in development
  • may not be able to perform self-care activities
  • will profit from habit training
  • will have some understanding of speech
51
Q

Profound intellectual delay

A
  • IQ <25
  • significant delay
  • minimal capacity to function
  • may respond to skill training
  • show basic emotions
52
Q

Fundal height is above the symphysis at ___-___ weeks gestation

A

12-24

53
Q

Fundal height is at the umbilicus or 20 cm at ___ weeks gestation

A

20

54
Q

Fundal height rises ___ cm/week until 36 weeks

A

1

55
Q

Total number of pregnancies regardless of duration (including present)

A

Gravida

56
Q

Number of pregnancies beyond period of viability (20 weeks or 500 g)

A

Para

57
Q

Quickening is maternal perception of fetal movement occurring between ___ and ___ weeks gestation

A

16; 20

58
Q

Total recommended weight gain throughout pregnancy

A

24-28 lbs

59
Q

Recommended weight gain during first trimester

A

2-4 lbs

60
Q

Recommended weight gain during second trimester

A

12-14 lbs

61
Q

Recommended weight gain during third trimester

A

8-12 lbs

62
Q

Presumptive signs of pregnancy

A
  • amenorrhea
  • morning sickness
  • breast sensitivity
  • fatigue
  • quickening
  • urinary frequency
63
Q

Probable signs of pregnancy

A
  • uterine enlargement
  • positive urine test
  • hegar’s sign: softening of isthmus of uterus
  • Chadwick’s sign: bluish discoloration of cervix
64
Q

Positive (definitive) signs of pregnancy

A
  • fetal heartbeat: 12 weeks by ultrasound, and 18-20 weeks by auscultation
  • palpation of fetal movement
  • visualization of fetus by ultrasound
65
Q

Normal FHR

A

120-160 bpm

66
Q

Normal fetal movement

A

Regular pattern of 10 movements in 20 minutes to 2 hours twice/day
NOTE: report less than 3 movements/hour

67
Q

Maternal alpha-fetoprotein test (AFT)

A
  • predicts neural tube defects (spinal bifida)
  • decreased levels may predict Down syndrome
  • done at 16-18 weeks gestation
68
Q

Ultrasound nursing consideration

A

Full bladder assists in clarity of image

69
Q

Favorable non-stress test (NST) result

A

2+ FHR accelerations of 15 bpm lasting 15 sec over a 20 min period

70
Q

Positive contraction stress test

A

Late decelerations with at least 50% of contractions; potential risk to fetus; C-section may be indicated

71
Q

Negative contraction stress test

A

No late decelerations with minimum of 3 contractions lasting 40-60 sec in 10 min period

72
Q

Danger signs of pregnancy

A
  • gush of fluid or bleeding from vagina
  • regular uterine contractions
  • severe headaches, visual disturbances, abdominal pain, persistent vomiting
  • fever or chills
  • swelling in face and fingers
  • decrease in fetal movement
73
Q

Latent phase of labor

A
  • 0-3 cm dilated
  • contractions 10-30 sec long, 5-30 min apart
  • mild to moderate intensity
74
Q

Active phase of labor

A
  • 4-7 cm dilated
  • contractions 30-40 sec long, 3-5 min apart
  • moderate to strong intensity
75
Q

Transition phase of labor

A
  • 8-10 cm dilated
  • contractions 45-90 sec long, 2-3 min apart
  • strong intensity
76
Q

Postpartum fundal height

A
  • at level of umbilicus for first 12 hours
  • descends by 1 fingerbreadth each day
77
Q

Postpartum lochia

A

Day 1-3: rubra (bloody)
Day 4-9: serosa (pink-brown)
Day 10+: alba (yellow-white)

78
Q

Abruptio placentae assessment

A
  • Painful vaginal bleeding
  • tender, painful abdomen
79
Q

It is important to test all women with average risk for diabetes at ___-___ weeks gestations

A

24-28

80
Q

Ectopic pregnancy assessment

A
  • unilateral lower quadrant pain
  • rigid, tender abdomen
  • referred shoulder pain
  • low Hct and hCG levels in blood and urine
  • bleeding
81
Q

Hydatidiform mole assessment

A
  • elevated hCG
  • uterine size larger than expected for dates
  • no fetal heart tones
  • minimal dark red/brown vaginal bleeding with grape-like clusters**
  • N/V
82
Q

Hydatidiform mole client education

A

Monitor hCG levels for 1 year, pregnancy discouraged for 1 year

83
Q

Mild preeclampsia

A
  • begins past 20th week
  • BP > 140/90 mm Hg
  • 2+ to 3+ proteinuria
  • slight generalized edema
84
Q

Severe preeclampsia

A
  • BP > 160/110 mm Hg
  • 4+ proteinuria
  • headache
  • epigastric pain
  • may develop pulmonary edema
  • hyperreflexia
85
Q

Eclampsia assessment

A
  • hypertension
  • proteinuria
  • tonic-clonic seizures
  • coma
86
Q

Placenta previa assessment

A
  • first and second trimester spotting
  • third trimester — painless, profuse bleeding
87
Q

Postpartum hemorrhage is defined as blood loss greater than _____ mL after a vaginal birth or _____ mL after a cesarean birth

A

500; 1000

88
Q

Postpartum blood loss is measured by weight perineal pads and is considered large if it exceeds ___ inches to saturated in _____

A

6; 1 hr

89
Q

Moderate postpartum blood loss

A

Greater than 4 inches but less than 6 inches in 1 hr

90
Q

Apgar score criteria

A
  • color
  • HR
  • reflexes
  • muscle tone
  • respirations
    NOTE: each category scored from 0-2
91
Q

Apgar scoring

A

< 3: critical
4-6: fair
7-10: normal

92
Q

Normal newborn respirations

A

30-60 breaths/min with short periods of apnea (<15 sec)

93
Q

Normal newborn blood pressure

A

65/40 in arm and calf

94
Q

Umbilical cord care

A

Keep it dry and exposed to air (will fall off after 1-2 weeks)

95
Q

Prevention of cold stress in newborns

A
  • delivery room set at 22 degrees Celsius (71 degrees Fahrenheit)
  • infant dried with pre-warmed towels and given a cap
  • skin to skin contact with mom
96
Q

Hypoglycemia in the infant is when the blood sugar is less than ___ mg/dL

A

35
NOTE: normal blood sugar is 40-80 mg/dL

97
Q

Breast self-examination

A
  • perform 1 week after onset of menstrual period OR on a designated day (first of month)
  • inspect breasts in mirror
  • examine with arms at sides, with arms above head, and with hands on hips
  • use pads of 3 middle fingers
  • assess for dimpling, discharge, changes
98
Q

Testicular self-examination

A
  • support testes in palm of hand
  • palpate between thumb and forefinger
  • perform during warm shower
  • perform monthly
99
Q

Diaphragm contraception patient education

A
  • fitted by HCP
  • do NOT insert > 6 hrs prior to sex
  • remove at least every 24 hours
  • higher risk of UTI and TSS
100
Q

Cranial nerve I

A
  • Olfactory
  • test this by having client smell an nonirritating substance with eyes closed; test each nostril separately
101
Q

Cranial nerve II

A
  • optic
  • test with snellen chart and ophthalmoscopic exam
102
Q

Cranial nerve III

A
  • oculomotor: controls pupil constriction and raising of eyelids
  • test by having client look up, down, and open eyes; shine penlight and assess PERRLA
103
Q

Cranial nerve IV

A
  • trochlear: controls downward and inward movement of eyes
  • test by having client look down and watch finger as moved towards client’s face
104
Q

Cranial nerve V

A
  • trigeminal: controls jaw movement, sensation on face and neck
  • test by touching both sides of face with pin and cotton; have client open jaw and bite down
105
Q

Cranial nerve VI

A
  • abducens: controls lateral movement of eyes
  • test by having client look up, down, and inward; have client watch finger go towards their face
106
Q

Cranial nerve VII

A
  • facial: controls facial movement and taste on anterior 2/3 of tongue
  • to test, have client frown, smile, and raise eyebrows; place sweet, sour, bitter, salty substances on tongue to assess taste
107
Q

Cranial nerve VIII

A
  • acoustic: controls sense of hearing and balance
  • to test, have client listen to ticking watch; have client stand with eyes closed to assess balance
108
Q

Cranial nerve IX

A
  • glossopharyngeal: controls swallowing and taste on posterior of tongue
  • assess by placing sweet, sour, bitter, salty substance on tongue; elicit gag reflex
109
Q

Cranial nerve X

A
  • vagus: controls swallowing and speech
  • instruct client to say “ahh” to assess soft palate and uvula; have client speak to assess quality of voice
110
Q

Cranial nerve XI

A
  • spinal accessory: controls flexion and rotation of head, shrugging of shoulders
  • assess by having client shrug shoulders against resistance, and move head side to side against resistance
111
Q

Cranial nerve XII

A
  • hypoglossal: controls tongue movement
  • assess by asking client to stick out tongue and move it quickly side to side
112
Q

The nurse performs a caloric test as part of the neurological assessment. Which information does the client need to know before the caloric test?

A

Vertigo and dizziness may occur during the examination
NOTE: this assesses cranial nerve 8

Kaplan NCLEX Review (6 decks)

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