Test 2 Flashcards
1
Q
- When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus?
a. 2 cm below the umbilicus
b. At the umbilicus
c. 1 cm below the umbilicus
d. Halfway between the umbilicus and the symphysis pubis
A
B.at the umbilicus
2
Q
What is the name of the vaginal discharge that occurs immediately following delivery?
a. Lochia serosa
b. Lochia rubra
c. Lochia palatine
d. Lochia alba
A
b. Lochia rubra
3
Q
What is the first secretion produced by the breast?
a. Prolactin
b. Colostrum
c. False milk
d. Whey
A
B. Colostrum
4
Q
What should be included in a teaching plan regarding breast engorgement?
a. It typically occurs on the first postpartum day.
b. It is usually first observed in the axillary region.
c. It occurs only in women who are not breastfeeding.
d. It occurs near the nipple on the third postpartum day.
A
b. It is usually first observed in the axillary region.
5
Q
When is breast engorgement most likely to occur?
a. When the infant’s mouth surrounds the areola when feeding
b. When the breast tissue becomes congested
c. When the breast is emptied completely at each feeding
d. When the infant’s mouth grasps the nipple firmly
A
b. When the breast tissue becomes congested
6
Q
Which statement would be a correct description of colostrum?
a. Slightly yellow and low in protein
b. Slightly yellow and provides antibodies
c. Creamy and high in fat and protein
d. Colorless and high in fat and carbohydrates
A
b. Slightly yellow and provides antibodies
7
Q
The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply?
a. Pump the breasts to remove milk
b. Apply warm, moist compresses
c. Restrict oral fluids
d. Apply a firm bra and ice packs
A
d. Apply a firm bra and ice packs
8
Q
During the immediate postpartum period, the mother has a temperature of 100.2°F (37.8°C), pulse 52, respirations 18, BP 138/84. What should the nurse do?
a. Report the temperature as abnormal.
b. Continue to monitor every 15 minutes.
c. Report the pulse as abnormal.
d. Nothing as the vital signs are normal.
A
d. Nothing as the vital signs are normal.
9
Q
Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurse’s reaction to the assessment?
a. This is a normal occurrence.
b. This is abnormal and should be reported.
c. The patient should be administered a blood thinner.
d. The patient should be restricted to bed rest.
A
a. This is a normal occurrence.
10
Q
What is the appropriate way to assess the fundus of the postpartum patient?
a. Using the side of one hand moving down from the umbilicus
b. Using one hand over the lower segment of the uterus
c. Using one hand pushing upward from the lower uterus
d. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
A
d. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
11
Q
The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do?
a. Offer a suppository or enema.
b. Encourage ambulation.
c. Offer stool softeners as prescribed.
d. Offer pain medication before defecating.
A
c. Offer stool softeners as prescribed.
12
Q
A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurse’s response when the mother asks to go the bathroom?
a. Assess her blood pressure.
b. Obtain a wheelchair.
c. Palpate her bladder.
d. Put slippers on her feet.
A
d. Put slippers on her feet.
13
Q
A mother delivered her baby at midnight and it is now 9 a.m. She wants to sleep and asks the nurse to take care of the baby. What is this considered?
a. Fatigue from labor
b. Normal “taking in” response
c. Abnormal “taking in” response
d. Risk for altered maternal-infant bonding
A
b. Normal “taking in” response
14
Q
Which of the following would be considered a normal assessment finding in a 1-day postpartum patient?
a. Pinkish to brown lochia
b. Voiding frequently 50 to 75 mL of urine
c. Complaining of “after pains”
d. Fundus 1 cm above the umbilicus
A
c. Complaining of “after pains”
15
Q
A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do?
a. Explain the importance of ambulating to recover.
b. Explain the importance of maternal-infant bonding.
c. Explore ways to blend this with safe health teaching.
d. Encourage this cultural behavior.
A
c. Explore ways to blend this with safe health teaching.
16
Q
Before initially feeding an infant, what reflex should the nurse assess?
a. Moro reflex
b. Rooting reflex
c. Babinski reflex
d. Swallow reflex
A
d. Swallow reflex
17
Q
Following delivery of the newborn, which nursing intervention should be carried out immediately?
a. Weigh the infant.
b. Warm the infant.
c. Bathe the infant.
d. Inoculate the infant.
A
b. Warm the infant.
18
Q
Where would acrocyanosis be assessed on a newborn?
a. Circumoral area
b. Brow
c. Feet
d. Mucous membrane
A
c. Feet
19
Q
The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent?
a. Physiologic
b. Normal
c. Pathologic
d. Transitory
A
c. Pathologic
20
Q
What is the term for the cream cheese–like substance that protects the infant’s skin from amniotic fluid?
a. Lanugo
b. Meconium
c. Desquamation
d. Vernix caseosa
A
d. Vernix caseosa
21
Q
Which tests are performed to detect inborn errors of metabolism in the newborn?
a. Blood glucose
b. Phenylketonuria (PKU)
c. Blood urea nitrogen (BUN)
d. Prothrombin time (PT
A
b. Phenylketonuria (PKU)
22
Q
Which newborn assessment finding can suggest a chromosomal disorder?
a. Epstein pearls
b. Gynecomastia
c. Babinski reflex
d. Simian crease
A
d. Simian crease
23
Q
Why is vitamin K given by injection to the newborn?
a. Most mothers have a vitamin K deficiency that develops during pregnancy.
b. Bacteria that synthesize vitamin K are not present in newborns.
c. Vitamin K prevents the synthesis of prothrombin.
d. The newborn does not store vitamin K.
A
b. Bacteria that synthesize vitamin K are not present in newborns.
24
Q
What should be included when discussing the care of a circumcised infant after discharge from the hospital?
a. Gently remove the yellow exudate from the foreskin.
b. Apply sterile petroleum gauze after each diaper change.
c. Wipe the circumcision with alcohol each day.
d. Avoid the use of cloth diapers until the foreskin has healed.
A
b. Apply sterile petroleum gauze after each diaper change.
25
The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care?
a. Administration of a topical anesthetic to the site
b. Application of ice to stop bleeding
c. Retraction of any remaining foreskin
d. Observation for bleeding for the first 12 hours
d. Observation for bleeding for the first 12 hours
26
Which finding should the nurse suspect as abnormal in the newborn during the initial assessment?
a. Eyes crossed at times
b. Persistent high-pitched cry
c. Arms and legs flexed
d. Slight bluish tinge of the extremities
b. Persistent high-pitched cry
27
What is a characteristic of a normal breast-fed infant’s stool?
a. Green and loose
b. Dark green and sticky
c. Pale yellow and frequent
d. Light brown and pasty
c. Pale yellow and frequent
28
The new mother calls the nurse to her room to show how her baby is “jerking around” when she changes his position. The nurse understands that the baby is exhibiting which normal reflex?
a. Traction reflex
b. Babinski reflex
c. Tonic neck reflex
d. Moro reflex
d. Moro reflex
29
The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration?
a. Apply baby powder generously to keep baby dry.
b. Cleanse perineum from front to back.
c. Use scented soap to make baby smell good.
d. Partially submerge head in water when shampooing.
b. Cleanse perineum from front to back.
30
1. Which of the following measures could help prevent infant abduction? (Select all that apply.)
a. Only transport infants by carrying them.
b. Require staff members to wear appropriate identification badges.
c. Respond immediately when an alarm sounds.
d. Never leave infants unattended at any time.
e. Take all the infants to their mothers at the same time.
b. Require staff members to wear appropriate identification badges.
c. Respond immediately when an alarm sounds.
d. Never leave infants unattended at any time.
31
The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring? (Select all that apply.)
a. The mother is making eye contact with the infant.
b. The mother is sending the infant to the nursery for feedings.
c. The mother is cuddling with the infant and napping.
d. The mother is requesting that the mother-in-law change all diapers.
e. The mother states that her favorite thing to do with her baby is to breastfeed.
a. The mother is making eye contact with the infant.
c. The mother is cuddling with the infant and napping.
e. The mother states that her favorite thing to do with her baby is to breastfeed.
32
A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother?
(Select all that apply.)
a. Prewarm the crib sheets with a hot water bottle
b. Swaddle the newborn tightly in a receiving blanket
c. Place the baby in a larger crib or infant bed
d. Offer a pacifier or allow the infant to suckle at the breast
e. Take the infant for a ride in the car
a. Prewarm the crib sheets with a hot water bottle
b. Swaddle the newborn tightly in a receiving blanket
d. Offer a pacifier or allow the infant to suckle at the breast
e. Take the infant for a ride in the car
33
After delivery of a 9-lb baby, the nurse assesses a perineal laceration extending through the muscles of the perineum. The nurse records this as a ________-degree laceration.
second
34
The nurse describes the return of the postpartum patient’s uterus to a pregravid state as ________________.
involution
35
The new mother tells the home health nurse that she is concerned about her 5-day-old infant’s hard, dried umbilical stump. What time frame should the nurse give the mother for the umbilical stump to fall off? 10 to 14 ___________.
days
36
1. A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions?
a. Hyperalimentation
b. IV fluids and electrolyte replacement
c. Hormone replacement therapy
d. Vitamin supplements
b. IV fluids and electrolyte replacement
37
A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse?
a. A large for gestational age infant
b. Anorexia nervosa
c. Preterm delivery
d. Maternal or fetal death
d. Maternal or fetal death
38
How should twins who share a placenta and come from one fertilized ovum be identified?
a. Dizygotic
b. Trizygotic
c. Genetically different
d. Monozygotic
d. Monozygotic
39
What complication of delivery should the nurse expect with the birth of multiple fetuses?
a. An ectopic tendency
b. Difficulty with breast-feeding
c. A vaginal delivery
d. Loss of uterine tone
d. Loss of uterine tone
40
A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient?
a. Long-term bed rest
b. Episodes of extreme hypertension
c. Surgery to remove the embryo/fetus
d. Treatment for dehydration
c. Surgery to remove the embryo/fetus
41
What percent of first-trimester pregnancies spontaneously abort?
a. 5% to 10%
b. 10% to15%
c. 20% to 25%
d. 40% to 50%
b. 10% to15%
42
What symptom, no matter what stage of pregnancy, should be reported immediately?
a. Backache
b. Urinary frequency
c. Vaginal bleeding
d. Uterine tightening
c. Vaginal bleeding
43
A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect?
a. Abruptio placentae
b. Hemorrhage
c. Placenta previa
d. Placentitis
c. Placenta previa
44
A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain?
a. Placenta previa
b. Appendicitis
c. Ectopic pregnancy
d. Abruptio placentae
d. Abruptio placentae
45
A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient?
a. Prone position
b. Trendelenburg’s position
c. Supine position
d. Modified side-lying position
d. Modified side-lying position
46
A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect?
a. Allergy
b. Protein deficiency
c. Circulatory problem
d. Gestational hypertension
d. Gestational hypertension
47
What condition is a possible cause of gestational hypertension?
a. Too much salt
b. A toxin
c. Renal disease
d. Diabetes
c. Renal disease
48
What should the nurse hope to identify by keeping a record of a patient’s blood pressure during prenatal visits?
a. Ketoacidosis
b. Placenta previa
c. Gestational diabetes
d. Gestational hypertension
d. Gestational hypertension
49
The nurse is assessing a “kick count” for a patient with gestational hypertension. What result should be a cause for concern?
a. Less than three kicks per hour
b. Less than five kicks per hour
c. Less than seven kicks per hour
d. Less than nine kicks per hour
a. Less than three kicks per hour
50
When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid?
a. Contacting with an infected person
b. Emptying cat litter boxes bare-handed
c. Having unprotected sex
d. Eating excessive amounts of shellfish
b. Emptying cat litter boxes bare-handed
51
What is a major complication of gestational diabetes that affects the infant?
a. Lack of nutrition
b. Dehydration
c. Hypoglycemia
d. Hyperglycemia
c. Hypoglycemia
52
A pregnant patient who has type 2 diabetes (NIDDM) may require insulin. Why is the insulin necessary?
a. The growing baby will require more glucose.
b. Oral hypoglycemic agents may be teratogenic.
c. Increased hormone levels raise blood glucose.
d. Oral hypoglycemics do not reach the fetus.
b. Oral hypoglycemic agents may be teratogenic.
53
Why is the fetus dependent on the mother for glucose control?
a. The insulin requirements are higher.
b. Insulin is destroyed by the placenta.
c. Insulin does not cross the placenta.
d. Insulin is absorbed by the fetus.
c. Insulin does not cross the placenta.
54
A patient with a history of rheumatic heart disease is being admitted to the labor and delivery unit. To prevent further stress on the heart, what should the nurse anticipate to be ordered?
a. Oxygen administration
b. Administering large amount of IV fluids
c. Positioning the patient on her back
d. Encouraging activity between contractions
a. Oxygen administration
55
A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem?
a. Calcium deficit
b. Cephalopelvic disproportion
c. Bleeding tendency
d. Low hemoglobin levels
b. Cephalopelvic disproportion
56
When should the gestational age of the infant be determined?
a. Within 5 to 10 minutes of delivery
b. Within 1 to 2 hours of delivery
c. Within 2 to 8 hours of delivery
d. Within 12 to 24 hours of delivery
c. Within 2 to 8 hours of delivery
57
The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant?
a. 20 to 37 completed weeks of pregnancy
b. 38 to 41 completed weeks of pregnancy
c. 14 to 36 completed weeks of pregnancy
d. 42 or more completed weeks of pregnancy
a. 20 to 37 completed weeks of pregnancy
58
Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants?
a. One to two times
b. Two to three times
c. Three to four times
d. Four to five times
c. Three to four times
59
A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant?
a. Full term
b. Small for gestational age
c. Preterm
d. Postterm
c. Preterm
60
A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies?
a. Rh-negative blood cells
b. Rh-positive blood cells
c. Rh-negative antibodies
d. Rh-positive antibodies
d. Rh-positive antibodies
61
The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection?
a. Iron
b. Vitamin B12
c. RhoGAM
d. Type O blood
c. RhoGAM
62
The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth?
a. Within normal limits
b. Pathologic
c. A result of iron deficiency
d. Indicating possible hepatitis
b. Pathologic
63
What test is used to identify the maternal level of Rh antibodies in the mother’s blood?
a. Indirect Coombs’ test
b. Hemolytic test
c. Rh antibody test
d. Direct Coombs’ test
a. Indirect Coombs’ test
64
A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy?
a. It is initiated when the bilirubin level reaches 5 mg/dL.
b. It converts bilirubin to a water-soluble form to be excreted in the urine.
c. It changes bilirubin to a bile salt to be excreted through the bowel.
d. It requires eye patches to remain in place 24 hours a day.
b. It converts bilirubin to a water-soluble form to be excreted in the urine.
65
Why do alcohol and illegal drugs endanger the fetus?
a. Both are absorbed into the bloodstream.
b. Both affect the mother.
c. Both cross the placental barrier.
d. Both increase the heart rate of the fetus.
c. Both cross the placental barrier.
66
Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus?
a. Fetal dependency
b. Fetal immaturity
c. Malnutrition dependency
d. Fetal alcohol syndrome
d. Fetal alcohol syndrome
67
What should be specifically monitored in a patient who is hospitalized with gestational hypertension?
a. Blood sugar
b. Temperature
c. Level of consciousness
d. Deep tendon reflexes
d. Deep tendon reflexes
68
What is the antidote for magnesium sulfate toxicity?
a. Vitamin K
b. Calcium gluconate
c. Potassium sulfate
d. Calcium carbonate
b. Calcium gluconate
69
What is a prominent feature of postpartum depression?
a. Failure to thrive
b. Rejection of the infant
c. Inability to care for the baby
d. Problems with the baby’s father
b. Rejection of the infant
70
What is the usual treatment for severe postpartum depression?
a. Improved nutrition
b. Vitamin therapy
c. Pharmacologic interventions
d. Support group therapy
c. Pharmacologic interventions
71
A pregnant patient with tuberculosis asks the nurse how the disease will affect her pregnancy and her newborn. What statements by the nurse are most appropriate? (Select all that apply.)
a. “You have nothing to worry about. You will be disease free before you deliver.”
b. “The tuberculosis can be transmitted to the fetus in rare occurrences.”
c. “Your newborn will be tested for tuberculosis after delivery.”
d. “There is no approved treatment for the infant if she tests positive for the
disease.”
e. “You will not be able to hold your newborn until you have been cleared according
b. “The tuberculosis can be transmitted to the fetus in rare occurrences.”
c. “Your newborn will be tested for tuberculosis after delivery.”
e. “You will not be able to hold your newborn until you have been cleared according
to the health department guidelines.”
72
Following an abruptio placentae, the patient suddenly becomes dyspneic, complains of chest pain, and begins to ooze blood from her IV insertion site. The nurse assesses these as indicators of disseminated ______________ coagulation.
intravascular
73
The nurse reports to the charge nurse that the 3-hour postpartum patient is bleeding excessively as she has saturated one peripad in less than ______ minutes.
15
fifteen
74
The nurse explains that severe _________________ needs to be controlled because it can develop into another syndrome called HELLP (Hypertension, Elevated Liver enzymes, and Low Platelets)
preeclampsia
75
The patient who has taken the ovulation stimulant clomiphene (Clomid), and who has been determined to be pregnant, calls the clinic nurse to report that she is bleeding and has passed a small grapelike object. From this information the nurse suspects a hydatidiform ____________.
mole
76
A woman who is 14 weeks’ pregnant calls the clinic nurse to report that after a brief bleeding episode a week ago, her uterus seems to have gotten smaller, but her periods have not begun. The nurse assesses the indicators for a _____________ abortion.
missed
77
1. The nurse stresses that regular physical activity has been identified as a leading health indicator. Regular physical activity has which positive effect on children?
a. Improves social skills.
b. Reduces fluid retention.
c. Increases bone and muscle strength.
d. Increases attention span.
c. Increases bone and muscle strength.
78
What is the single most preventable cause of death and disease in the United States today?
a. Drug use
b. Alcohol addiction
c. Cigarette smoking
d. Malnutrition
c. Cigarette smoking
79
Smoking contributes to an increased risk of heart and lung disease in children by which methods?
a. Air pollution
b. Allergens in the environment
c. Environmental smoke
d. Lack of oxygen in the air
c. Environmental smoke
80
Which factor is mostly associated with problems such as domestic violence, sexually transmitted infections (STIs), school failure, and motor vehicle accidents (MVAs)?
a. Lack of supervision
b. Psychological problems
c. Substance abuse
d. Physiological problems
c. Substance abuse
81
Approximately half of all new HIV cases are among people under what age?
a. 50 years
b. 40 years
c. 30 years
d. 25 years
d. 25 years
82
Which children must be secured in the back seat in a rear-facing safety seat?
a. Children weighing up to 20 lb
b. Children weighing between 20 and 30 lb
c. Children weighing between 30 and 40 lb
d. Children weighing more than 40 lb
a. Children weighing up to 20 lb
83
The pediatric nurse reminds the parents of a 2-year-old that by this age the child should be protected against how many vaccine-preventable childhood diseases?
a. 4
b. 6
c. 8
d. 10
d. 10
84
A major dental problem among very young children is bottle mouth caries. What is a preventive measure the nurse should suggest?
a. Juice at bedtime
b. Milk at bedtime
c. A sugar-coated pacifier
d. Water at bedtime
d. Water at bedtime
85
What practice should be used by a pediatric nurse to remind parents of their responsibility in reducing the number of accidents involving children?
a. Child awareness
b. Good manners
c. Anticipatory guidance
d. Strict discipline
c. Anticipatory guidance
86
To prevent accidental poisoning of a child, where should medications be placed in the home?
a. In a dresser drawer
b. In the medicine cabinet
c. In a locked cupboard
d. On a high shelf
c. In a locked cupboard
87
What is the leading cause of fatal injury in children younger than 1 year old?
a. Burns
b. Poisons
c. Asphyxiation
d. Motor vehicle accidents
c. Asphyxiation
88
What is the third leading cause of accidental death in children 1 to 4 years of age?
a. Falls
b. Asphyxiation
c. Poisons
d. Burns
d. Burns
89
The school nurse recognizes that lack of physical activity and increased consumption of fast food by children are causative factors contributing to which of the following problems?
a. Nutritional disorders
b. Weight gain
c. Type I diabetes
d. Dental caries
b. Weight gain
90
The nurse sets up a sample physical activities schedule to fit the FDA’s Dietary Guidelines for Americans that recommends that children get at least how many minutes of physical activity per day?
a. 15
b. 30
c. 45
d. 60
d. 60
91
What age group is experiencing the largest increase in drug use?
a. 7- to 9-year-olds
b. 10- to 12-year-olds
c. 12- to 13-year-olds
d. 15- to 17-year-olds
c. 12- to 13-year-olds
92
Because the water in the infant’s residential area is not fluoridated, when should the nurse suggest that the infant receive supplemental fluoride?
a. 2 months old
b. 4 months old
c. 5 months old
d. 6 months old
d. 6 months old
93
What are reasons that a pediatric nurse should stress that health promotion activities must be ongoing? (Select all that apply.)
a. To identify health risks
b. To encourage healthy behavior
c. To strengthen family bonds
d. To improve nutrition
e. To prevent accidents
a. To identify health risks
b. To encourage healthy behavior
d. To improve nutrition
e. To prevent accidents
94
The school nurse collaborates with the physical education instructor to increase the amount of physical activity during the school day. What are major benefits of physical activity? (Select all that apply.)
a. Reduced death rates as adults
b. Reduced risk of cardiovascular disease
c. Reduced risk of hypertension
d. Reduced risk of diabetes
e. Reduced self-esteem
a. Reduced death rates as adults
b. Reduced risk of cardiovascular disease
c. Reduced risk of hypertension
d. Reduced risk of diabetes
95
Which are physical risks associated with excess weight? (Select all that apply.)
a. Poor eyesight
b. Heart disease
c. Arthritis
d. Stroke
e. Appendicitis
b. Heart disease
c. Arthritis
d. Stroke
96
Which of the following interventions should be included when teaching a healthy behaviors class for parents of adolescents?
(Select all that apply.)
a. Always monitor the child’s telephone conversations.
b. Insist on seatbelt use at all times.
c. Encourage tanning bed use versus exposure to the sun.
d. Maintain recommended immunization schedule.
e. Encourage good dental care.
b. Insist on seatbelt use at all times.
d. Maintain recommended immunization schedule.
e. Encourage good dental care.
97
A nurse emphasizes a study that focused on the amount of time children spend using various media, such as TV, video games, and computers, and stated that by cutting this time by ____%, it would have a significant impact on increasing physical activity.
50
98
The nurse recognizes that preventive programs in schools must be stepped up in order to prevent violence, especially __________.
shootings
99
1. What was one of the major strides in pediatric care made by Dr. Abraham Jacobi?
a. Pediatric wards in hospitals
b. Free inoculations against smallpox
c. Milk stations in the city of New York
d. Serving nutritious foods in orphanages
c. Milk stations in the city of New York
100
What was founded by Lillian Wald?
a. National Commission on Children
b. Henry Street Settlement
c. White House Conference
d. US Children’s Bureau
b. Henry Street Settlement
101
When the pediatric nurse is attempting to establish a trusting relationship with a child, what is the most important and lasting thing to do?
a. Convey respect.
b. Talk with the child.
c. Be honest.
d. Talk with family.
c. Be honest.
102
What is the special category that encompasses children who have congenital abnormalities, malignancies, gastrointestinal (GI) diseases, or central nervous system (CNS) anomalies?
a. Very dependent children
b. Children requiring special education
c. Children with special needs
d. Children requiring long-term care
c. Children with special needs
103
The mother of a child with diabetes asks the nurse in charge of the family-centered pediatric unit if she might see her child’s laboratory reports. What response by the nurse is the most appropriate?
a. “Although the actual reports are not shared, I can tell you the blood sugar is 200
mg.”
b. “I’ll write them down for you and bring them to your room.”
c. “Come to the conference room where we can have privacy while you look at
them.”
d. “I’ll notify the health care provider that you wish to see the reports.”
c. “Come to the conference room where we can have privacy while you look at
them.”
104
What should be the focus of a practice where the pediatric nurse uses a developmental approach?
a. Stimulation of the child to reach expected norms
b. Age-centered care plans
c. Strengths and abilities of the child
d. Characteristics for the particular age
c. Strengths and abilities of the child
105
When using anticipatory guidance to prepare a 5-year-old for an IM injection, what statement by the nurse would be most appropriate?
a. “Ethan, I’m going to give you a shot.”
b. “Ethan, the health care provider wants you to have some medicine, and it will
hurt.”
c. “Ethan, some medicine can only be given with a needle.”
d. “Ethan, I am going to give you some medicine that will sting, but only for a little
while.”
d. “Ethan, I am going to give you some medicine that will sting, but only for a little
while.”
106
When measuring the head circumference of an infant, where should the nurse place the tape measure?
a. Across the eyebrows and around the occipital lobe
b. Over the zygomatic arches and around the parietal areas
c. Around forehead and around the crown of the head
d. Above the eyebrows and pinnas, and around the occipital lobe
d. Above the eyebrows and pinnas, and around the occipital lobe
107
What activity by an infant would cause a false elevation of the tympanic temperature?
a. Having a bowel movement
b. Crying vigorously
c. Having just eaten
d. Having been in a cold room
b. Crying vigorously
108
Why does obtaining the respirations of an infant require a modified approach from that of an adult?
a. Infants breathe through their noses.
b. Infants have very rapid respirations.
c. Infants’ respirations are thoracic in nature.
d. Infants’ respiratory movements are abdominal.
d. Infants’ respiratory movements are abdominal.
109
An 8-year-old child asks how a blood pressure is taken. What would be the most appropriate response?
a. “This small machine will measure your systolic and diastolic pressure.”
b. “The armband will hug your arm and tell me how well your blood is going
through your arm.”
c. “The armband will cut off your circulation for a while and then we can hear when
it comes back.”
d. “When you are ill we need to know if your blood is still moving in your body.”
b. “The armband will hug your arm and tell me how well your blood is going
through your arm.”
110
What is the correct way to assess for the presence of jaundice in an African-American child?
a. Examine the sclera.
b. Press the edge of the pinna.
c. Apply pressure to the gum.
d. Compare the color on the soles of the feet.
c. Apply pressure to the gum.
111
When discussing growth and development with the parents of a child, the nurse explains that nutrition is the single most important influence on:
a. cognitive development.
b. secondary sexual characteristics.
c. the production of blood cells.
d. the growth of bones and muscle.
d. the growth of bones and muscle.
112
The mother of a 3-year-old expresses concern about her daughter’s slowed growth rate. What would be the most informative response by the nurse?
a. “Three-year-olds have typically finished a growth spurt, and you may notice a
decreased rate in your daughter’s growth.”
b. “Children’s growth is hereditary. She may be of small stature like you.”
c. “The growth of a 3-year-old is associated with their nutrition. How is she eating?”
d. “Your daughter is healthy and happy. Don’t worry about her growth right now.”
a. “Three-year-olds have typically finished a growth spurt, and you may notice a
decreased rate in your daughter’s growth.”
113
What should be included in the teaching plan for the parents of a 3-year-old child who has been prescribed an opioid analgesic?
a. The opioid is likely to cause significant respiratory depression.
b. The medicine is prescribed with the knowledge that addiction may occur.
c. The opioid is very effective as a pain control method.
d. The opioid is only to be given in cases of severe pain.
c. The opioid is very effective as a pain control method.
114
The parents ask about preparation of their toddler for hospital admission. When does the nurse suggest that the parents tell their toddler of the admission?
a. A week prior
b. 2 weeks prior
c. The day of admission
d. Only 2 or 3 days before
d. Only 2 or 3 days before
115
When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. What statement by the nurse will be most helpful to the mother?
a. “Don’t be concerned. Accidents happen.”
b. “Let’s put a diaper on your child until this gets better.”
c. “The stress of hospitalization makes children regress a little.”
d. “Your child will relearn ‘potty-training’ if you are patient.”
c. “The stress of hospitalization makes children regress a little.”
116
When attempting to provide information to the parents of a child undergoing surgery, the nurse notes that the parents appear confused and do not seem to remember what they are being told. What is the most probable cause of the parents’ forgetfulness?
a. Noisy environment
b. Serious nature of surgery
c. Increased level of parents’ anxiety
d. Developmental age of the child
c. Increased level of parents’ anxiety
117
What is the best time to bathe an infant?
a. At bedtime
b. Early in the morning
c. After a feeding
d. Before a feeding
d. Before a feeding
118
How should an infant be positioned after a feeding?
a. On the stomach
b. On the right side
c. On the left side
d. On the back
b. On the right side
119
When a safety reminder device (SRD) is used to protect a child, what is a responsibility of the nurse?
a. Apply it loosely.
b. Remove it every 2 hours.
c. Place it over clothing.
d. Apply only one type.
b. Remove it every 2 hours.
120
What should be done before initiating a gavage feeding?
a. Hold the feeding tube under water to check for bubbling.
b. Check for gastric distention.
c. Aspirate stomach contents.
d. Ensure the sterility of feeding equipment.
c. Aspirate stomach contents.
121
What is the purpose of a mist tent?
a. To provide a constant oxygen supply
b. To liquefy respiratory secretions
c. To aid in lowering temperature
d. To improve the infant’s hydration
b. To liquefy respiratory secretions
122
What is the maximum amount of time that a nurse should suction an artificial airway?
a. 1 second
b. 5 seconds
c. 30 seconds
d. 1 minute
b. 5 seconds
123
What is a disadvantage of using a mist tent with a toddler?
a. The nurse must remove the restless child.
b. The wet bedding and clothing must be changed frequently.
c. The mist tent must be opened at least once every hour.
d. All objects must be kept outside of the tent.
b. The wet bedding and clothing must be changed frequently.
124
What is one way to enhance the nutrition of the hospitalized toddler?
a. Reward with sweets for eating meals.
b. Discourage participation in noneating activities.
c. Offer nutritious fluids frequently.
d. Leave nutritious finger foods out for the child to eat.
c. Offer nutritious fluids frequently.
125
Why must the pediatric nurse be cautious about medicating infants and young children?
a. They are less susceptible to medication effects than adults.
b. They are more susceptible to medication effects than adults.
c. They are equally susceptible to medication effects as adults.
d. They are more susceptible to drug interactions than adults.
b. They are more susceptible to medication effects than adults.
126
What is the preferred IM injection site for a 2-year-old?
a. Deltoid muscle
b. Upper thigh
c. Vastus lateralis
d. Gluteus
c. Vastus lateralis
127
Where is the typical IV insertion site in an infant younger than 9 months of age?
a. Radial vein
b. Scalp vein
c. Femoral vein
d. Brachial vein
b. Scalp vein
128
Following a lumbar puncture of a 2-year-old, what should the nurse do?
a. Keep the child flat for several hours.
b. Allow the child to play quietly at will.
c. Hold the child in a flexed position for 5 minutes.
d. Stand the child upright immediately.
b. Allow the child to play quietly at will.
129
What should the nurse do to minimize an unpleasant-tasting drug?
a. Pour the drug over ice.
b. Squirt the drug in the mouth with a syringe.
c. Administer the drug through a straw.
d. Enlist the parent’s assistance.
c. Administer the drug through a straw.
130
A disfiguring facial wound would have the most significant developmental impact on which child?
a. 4-year-old
b. 6-year-old
c. 10-year-old
d. 14-year-old
c. 10-year-old
131
When the nurse is inserting a feeding tube in an 8-month-old, what safety reminder device (SRD) should the nurse most likely use?
a. Mummy
b. Clove hitch
c. Jacket device
d. Elbow device
a. Mummy
132
The nurse clarifies that child abuse and neglect are complicated and preventable problems falling under which broader term?
a. Child abandonment
b. Child mismanagement
c. Child maltreatment
d. Child torment
c. Child maltreatment
133
What observation in an emergency department should lead a nurse to suspect child abuse in a child with a fractured arm?
a. Lack of parental concern for the severity of the injury
b. The child not answering questions concerning the injury
c. Parents not asking about the child’s condition
d. Inconsistency between the injury and the parents’ explanation of it
d. Inconsistency between the injury and the parents’ explanation of it
134
When communicating with parents suspected of child abuse, what should the nurse be sure to do?
a. Tell them the law requires reporting of the incident.
b. Be sympathetic to their needs.
c. Interact with them in a nonjudgmental manner.
d. Suggest psychiatric counseling.
c. Interact with them in a nonjudgmental manner.
135
After observing parental behavior that leads the nurse to suspect child abuse, when should the nurse report the abuse?
a. If the parent confesses to child abuse
b. If the child admits to being abused
c. Whenever maltreatment of a child is suspected
d. When the type of abuse can be determined
c. Whenever maltreatment of a child is suspected
136
The nurse welcomes the presence of the family in a pediatric unit because it reduces the stressors of hospitalization. Which are common stressors for the hospitalized child? (Select all that apply.)
a. Separation
b. Lack of love
c. Fear of pain
d. Unfamiliar food
e. Loss of control
a. Separation
c. Fear of pain
e. Loss of control
137
The nurse clarifies that the family-centered care approach terminates which policies? (Select all that apply.)
a. Rigid visiting hours
b. Freedom to choose which medications to take
c. Exclusion of family during procedures
d. Discouraging family to stay overnight
e. Restricting parents from reading the chart
a. Rigid visiting hours
c. Exclusion of family during procedures
d. Discouraging family to stay overnight
e. Restricting parents from reading the chart
138
The pediatric nurse, along with the primary caregiver(s), has a special duty to ________ the child and the family.
teach
139
The nurse is aware that visual acuity evaluation in a child is best assessed after the age of _____ years.
6
140
What is the correct order for assessing vital signs in an infant to ensure the accuracy of measurements?
a. Respiration, temperature, pulse
b. Pulse, respiration, temperature
c. Temperature, pulse, respiration
d. Respiration, pulse, temperature
d. Respiration, pulse, temperature
