Sample Chapter

Maternity and Pediatric Nursing 1st (first) Edition by Ricci, Susan Scott – Test Bank
Sample  Questions



Ch. 1: Perspectives on Maternal and Child Health Care



Page:  9
1. The United States ranks 21st for maternal mortality and 27th for infant mortality rates when compared to the rest of the world. Which factor has the greatest impact on decreasing these rates?
A) Resolving all language and cultural differences
B) Ensuring early and adequate prenatal care
C) Providing more extensive women’s shelters
D) Encouraging all women to eat a balanced diet
Ans: B
The lack of prenatal care during pregnancy is a major factor contributing to a poor outcome. Prenatal care is well known to prevent complications of pregnancy and to support the birth of healthy infants. Infant mortality commonly includes problems occurring at birth or shortly thereafter. Thus, ensuring early and adequate prenatal care would have the greatest impact on decreasing these rates. Resolving all language and cultural differences would be helpful but is unrealistic. Providing more extensive women’s shelters would be helpful for women who are victims of abuse. Encouraging all women to eat a balanced diet is helpful but would not decrease infant mortality rates.



Page:  6
2. When integrating the principles of family-centered care, the nurse would include which of the following?
A) Childbirth is viewed as a medical event.
B) Families are unable to make informed choices.
C) Childbirth results in changes in relationships.
D) Families require little information to make appropriate decisions.
Ans: C
Family-centered care is based on the following principles. Childbirth affects the entire family and relationships will change. Childbirth is viewed as a normal, healthy event in the life of the family. Families are capable of making decisions about their own care if given adequate information and professional support.



Page:  5
3. When preparing a teaching plan for a group of women who are pregnant for the first time, the nurse expects to review how maternity care has changed over the years. Which of the following would the nurse include when discussing events of the 20th century?
A) Epidemics of puerperal fever
B) First cesarean birth
C) X-rays used to assess pelvic size
D) Development of free-standing birth centers
Ans: D
In the 20th century (1900s), free-standing birth centers were developed. Puerperal fever epidemics, the first cesarean birth, and the use of x-rays to assess pelvic size were events occurring during the 19th century (1800s).



Page:  9
4. Which of the following is the most common cause of pregnancy-related mortality?
A) Hemorrhage
B) Embolism
C) Hypertension
D) Infection
Ans: B
According to the most recent statistics available, embolism is the leading cause of pregnancy-related mortality, accounting for 20% of deaths. This is followed by hemorrhage (17%), pregnancy-related hypertension (16%), and infection (13%).



Page:  11
5. The nurse is working with a group of community leaders to develop a plan to address the special health needs of women. Which of the following conditions would the group address as the major problem?
A) Smoking
B) Heart disease
C) Diabetes
D) Cancer
Ans: B
The group needs to address cardiovascular disease, the number-one cause of death in women regardless of racial or ethnic group. Smoking is related to heart disease and cancer, although heart disease and cancer can occur in any woman regardless of her smoking history. Cancer is the second leading cause of death, with women having a one in three lifetime risk of developing cancer. Diabetes is another important health condition that can affect women, but it is not the major health problem that heart disease is.



Page:  29
6. When assessing a family for barriers to health care, the nurse would consider which factor to be most important?
A) Language
B) Health care workers’ attitudes
C) Transportation
D) Finances
Ans: D
Financial barriers are one of the most important factors that limit care. Families may not have any medical insurance, may not have enough insurance to cover the services they need, or may not be able to pay for services. Language, health care workers’ attitudes, and transportation are also barriers to health care but are not as fundamentally important as finances.



Page:  6
7. A 3-year-old boy with encephalitis is scheduled for a lumbar puncture. Which of the following actions by the nurse would demonstrate atraumatic care?
A) Using EMLA prior to lumbar puncture
B) Having his anxious mother stay in the waiting room
C) Explaining, using medical terms, what will happen
D) Starting the child’s intravenous infusion in his room
Ans: A
Using EMLA prior to the lumbar puncture reduces the pain associated with the procedure and is an example of atraumatic care. The presence of a parent during procedures is supportive for the child and should be encouraged because it can reduce stress. The explanation of what will happen should be given on the child’s level. The IV should not be started in the child’s hospital room, which should remain a “safe” area.



Page:  7
8. The nurse is caring for a 14-year-old girl with multiple health problems. Which of the following activities would best reflect evidence-based practice by the nurse?
A) Following blood pressure monitoring recommendations
B) Determining how often vital signs are monitored
C) Using hospital protocol for ordering diagnostic tests
D) Deciding on the medication dose
Ans: A
Using hospital protocol for ordering a diagnostic test, determining how often vital signs are monitored, and deciding on the medication dose would be the physician’s responsibility. However, following blood pressure monitoring recommendations would be part of evidence-based practice reflected in the nursing care delivered.



Page:  8
9. The nurse is providing care to an ill child and his family. Which of the following activities would deviate from the basic principles of case management?
A) Collaborating with the family throughout the care path
B) Focusing on both the client’s and the family’s needs
C) Coordinating care provided by the interdisciplinary team
D) Ensuring quality care regardless of the cost
Ans: D
Ensuring quality care regardless of the cost is not part of case management, but providing cost-effective, high-quality care is. Collaborating with the family throughout the care path, coordinating care provided by the interdisciplinary team, and focusing on client and family needs are key components of case management that increase family satisfaction.



Page:  15
10. A 10-year-old girl who is living with a foster family is brought to the clinic for evaluation. When caring for this child, which intervention is a priority?
A) Determining if the child is being bullied at school
B) Dealing with mixed expectations of parents
C) Establishing who the child’s actual caretaker is
D) Performing a comprehensive health assessment
Ans: D
The child may have lived with several different families and may not have complete medical files, so performing a comprehensive health assessment will be important. Determining if the child is being bullied at school is not specific to any one family structure. Assessing for problems related to mixed expectations of parents is common in a blended family. Establishing who the caretaker is would be necessary with a communal family.



Page:  16
11. The mother of an 8-year-old girl with a broken arm is the nurturer in the family. The mother would be the focus of which activity?
A) Teaching proper care procedures
B) Dealing with insurance coverage
C) Determining success of treatment
D) Transmitting information to family members
Ans: A
The mother is the nurturer and thus the primary caregiver, so she would be the best family member to learn proper care procedures. Dealing with insurance coverage is the responsibility of the family’s financial manager, transmitting information to family members is the gatekeeper’s duty, and determining the success of treatment would likely fall to the family decision maker.



Page:  18
12. The nurse is teaching discipline strategies to the parents of a 4-year-old boy. Which response by the parents indicates a need for more teaching?
A) “We should remove temptations that lead to bad behavior.”
B) “We need to explain how we expect him to behave.”
C) We should tell him we get angry when he’s bad.”
D) “We must praise the child for good behavior.”
Ans: C
This response indicates the need to restate that it is important to let the child know that it is not him but rather his behavior that is bad. Removing temptations, setting expectations, and praising good behavior are important concepts the parents need to learn.



Page:  18
13. A mother confides to the nurse that she is thinking of divorce. Which suggestion by the nurse would be most helpful in minimizing the effects of the divorce on the couple’s son?
A) Tell him together, using appropriate terms.”
B) “Reassure him that no one loves him more than you.”
C) “Do special things with him to make up for the divorce.”
D) “Share your feelings about your spouse with the child.”
Ans: A
Both parents should tell the child about the divorce together, using appropriate terms. The other responses are unacceptable behaviors for the mother, such as competing with the spouse and using the child as a confidant.



Page:  18
14. The nurse is teaching discipline strategies to the parents of a 12-year-old girl. Which of the following topics is an example of positive reinforcement discipline?
A) Unplugging the DVD player for the weekend
B) Taking a chore away from the child for a week
C) Having her clean up the kitchen for a week
D) Ignoring her request if she doesn’t say “please”
Ans: B
Taking a chore away from the child for a week is an excellent way to reward her for positive behavior. Unplugging the DVD player and assigning an extra chore are examples of negative reinforcement. Ignoring her until she uses good manners is an example of extinction.



Page:  21
15. Parents are complaining about the amount of time their 14-year-old girl spends on the Internet. Which of the following would be most important to address with the parents?
A) “Limit her use of the Internet to an hour per day.”
B) Does she do her homework and socialize in person?
C) “Place the computer where you can keep an eye on her.”
D) “You need to warn her about protecting her identity.”
Ans: B
Although having the computer in a family area is better than putting it in her room, and warning her about protecting her identity is key, it is important to determine if the child is neglecting responsibilities, schoolwork, household activities, friends, or other forms of personal interaction. Once this is determined, then reasonable time limits for the child’s use of the Internet can be established.



Page:  35
16. A preschool child is scheduled to undergo a diagnostic test. Which action by the nurse would violate a child’s bill of health care rights?
A) Arranging for her mother to be with her
B) Telling the child the test will not hurt
C) Assuring the child that the test will be done quickly
D) Introducing the child to the lab technicians
Ans: B
Telling the child the test will not hurt lacks veracity. It is not a lie, but it does not honor the child’s right to be educated honestly about his or her health care. Arranging for the mother to be with the child, assuring the child that the test will be done quickly, and introducing the child to the lab technicians are actions that honor the child’s bill of health care rights.



Page:  32
17. The school nurse is trying to get consent to care for an 11-year-old boy with diabetic ketoacidosis. His parents are out of town on vacation and the child is staying with a neighbor. Which action would be the priority?
A) Getting telephone consent, with two people listening to the verbal consent
B) Providing emergency care without parental consent
C) Contacting the child’s aunt or uncle to obtain consent
D) Advocating for parens patriae to proceed with care for the child
Ans: A
The priority action would be to contact the neighbor for an emergency number to reach the parents and get their verbal consent, with two witnesses listening simultaneously. If the nurse cannot reach the parents and there is no relative or other person with written authorization to act on the parent’s behalf, then the physician may initiate emergency care without the parent’s consent. Parens patriae would be reserved for situations where the parents are neglectful, irresponsible, or incompetent.



Page:  33
18. A 9-month-old with glaucoma requires surgery. The infant’s parents are divorced. To obtain informed consent, which action would be most appropriate?
A) Contacting the father for informed consent
B) Obtaining informed consent from the mother
C) Seeking a court ruling on the course of care
D) Determining whether there is sole or joint custody by the parents
Ans: D
The most appropriate action would be to determine legal custody by court decree. If the parents have joint custody, then either parent may give consent, but it is always best to have consent given by both parents. The parent with only physical custody may give consent for emergency care. The last resort is getting a court ruling; usually this is not necessary unless the parents disagree about the care of the child.


Ch. 3: Anatomy and Physiology of the Reproductive System



1. When describing the menstrual cycle to a group of young women, the nurse explains that estrogen levels are highest during which phase of the endometrial cycle?
A) Menstrual
B) Proliferative
C) Secretory
D) Ischemic
Ans: B
Estrogen levels are the highest during the proliferative phase of the endometrial cycle, when the endometrial glands enlarge in response to increasing amounts of estrogen. Progesterone is the predominant hormone of the secretory phase. Levels of estrogen and progesterone drop sharply during the ischemic phase and fall during the menstrual phase.



2. After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman’s first:
A) Sexual experience
B) Full hormonal cycle
C) Menstrual period
D) Sign of breast development
Ans: C
Menarche is defined as the establishment of menstruation. It does not refer to the woman’s first sexual experience, full hormonal cycle, or sign of breast development.



3. A client with a 28-day cycle reports that she ovulated on May 10. The nurse would expect the client’s next menses to begin on:
A) May 24
B) May 26
C) May 30
D) June 1
Ans: A
For a woman with a 28-day cycle, ovulation typically occurs on day 14. Therefore, her next menses would begin 14 days later, on May 24.



4. Which female reproductive tract structure would the nurse describe to a group of young women as containing rugae that enable it to dilate during labor and birth?
A) Cervix
B) Fallopian tube
C) Vagina
D) Vulva
Ans: C
The vagina is a tubular, fibromuscular organ lined with mucous membrane that lies in a series of transverse folds called rugae. These rugae allow for extreme dilation of the canal during labor and birth. The cervix, the lower portion of the uterus, is composed of fibrous connective tissue that dilates during labor. The fallopian tube transports the ovum from the ovary to the uterus. The vulva is a collective term used to refer to the external female reproductive organs (mons pubis, labia majora and minora, clitoris, vestibular structures, and perineum).



5. After teaching a group of pregnant women about breastfeeding, the nurse determines that the teaching was successful when the group identifies which hormone as important for the production of breast milk after childbirth?
A) Placental estrogen
B) Progesterone
C) Gonadotropin-releasing hormone
D) Prolactin
Ans: D
After childbirth and expulsion of the placenta, prolactin stimulates the production of milk. Placental estrogen and progesterone stimulate the development of the mammary glands during pregnancy. Gonadotropin-releasing hormone induces the release of follicle-stimulating hormone and luteinizing hormone to assist with ovulation.



6. The nurse is assessing a 13-year-old girl. Which of the following events would the nurse expect to have occurred first?
A) Evidence of pubic hair
B) Development of breast buds
C) Onset of menses
D) Growth spurt
Ans: B
Pubertal events preceding the first menses have an orderly progression beginning with the development of breast buds, followed by the appearance of pubic hair, then axillary hair, then a growth spurt. Menses typically occurs about 2 years after the start of breast development.



7. When describing the ovarian cycle to a group of students, which phase would the instructor include?
A) Luteal phase
B) Proliferative phase
C) Menstrual phase
D) Secretory phase
Ans: A
The ovarian cycle consists of three phases: the follicular phase, ovulation, and the luteal phase. The endometrial cycle includes the proliferative phase, menstrual phase, and secretory phase.



8. The nurse is explaining the events that lead up to ovulation. Which hormone would the nurse identify as being primarily responsible for ovulation?
A) Estrogen
B) Progesterone
C) Follicle-stimulating hormone
D) Luteinizing hormone
Ans: D
At ovulation, a mature follicle ruptures in response to a surge of luteinizing hormone. Estrogen is predominant at the end of the follicular phase, directly preceding ovulation. Progesterone peaks 5 to 7 days after ovulation. Follicle-stimulating hormone is highest during the first week of the follicular phase of the cycle.



9. The nurse is teaching a health education class on male reproductive anatomy and asks the students to identify the site of sperm production. Which structure, if identified by the group, would indicate to the nurse that the teaching was successful?
A) Testes
B) Seminal vesicles
C) Scrotum
D) Prostate gland
Ans: A
The testes are responsible for sperm production. The seminal vesicles produce nutrient seminal fluid. The scrotum surrounds and protects the testes. The prostate gland and the seminal vesicles produce fluid to nourish the sperm.



10. The nurse is creating a diagram that illustrates the components of the male reproductive system. Which structure would be inappropriate for the nurse to include as an accessory gland?
A) Seminal vesicles
B) Prostate gland
C) Cowper’s glands
D) Vas deferens
Ans: D
The vas deferens is part of the ductal system of the male reproductive system responsible for transporting sperm from the epididymis. Accessory glands include the seminal vesicles, prostate gland, and Cowper’s or bulbourethral glands.



11. The nurse is preparing an outline for a class on the physiology of the male sexual response. Which event would the nurse identify as occurring first?
A) Sperm emission
B) Penile vasodilation
C) Psychological release
D) Ejaculation
Ans: B
With sexual stimulation, the arteries leading to the penis dilate and increase blood flow into erectile tissue. Blood accumulates, causing the penis to swell and elongate. Sperm emission (movement of sperm from the testes and fluid from the accessory glands) occurs with orgasm. Orgasm results in a pleasurable feeling of physiologic and psychological release. Ejaculation results in the discharge of semen from the urethra.



12. A woman comes to the clinic complaining that she has little sexual desire. As part of the client’s evaluation, the nurse would anticipate the need to evaluate which hormone level?
A) Progesterone
B) Estrogen
C) Gonadotropin-releasing hormone
D) Testosterone
Ans: D
Testosterone is thought to be the hormone of sexual desire in women. Thus, an evaluation of this level would be done. Progesterone is often called the hormone of pregnancy because of its calming effect (reduction in uterine contractions) on the uterus, allowing pregnancy to be maintained. Estrogen is the predominant hormone at the end of the follicular phase. Gonadotropin-releasing hormone induces the release of FSH and LH to assist with ovulation.


Ch. 11: Maternal Adaptation During Pregnancy



Page:  290
1. During a vaginal exam, the nurse notes that the cervix has a bluish color. The nurse documents this finding as:
A) Hegar’s sign
B) Goodell’s sign
C) Chadwick’s sign
D) Ortolani’s sign
Ans: C
Bluish coloration of the cervix is termed Chadwick’s sign. Hegar’s sign refers to the softening of the lower uterine segment or isthmus. Goodell’s sign refers to the softening of the cervix. Ortolani’s sign is a maneuver done to identify developmental dysplasia of the hip in infants.



Page:  292
2. The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time?
A) Dysuria
B) Dyspnea
C) Constipation
D) Urinary frequency
Ans: D
Lightening refers to the descent of the fetal head into the pelvis and engagement. With this descent, pressure on the diaphragm decreases, easing breathing, but pressure on the bladder increases, leading to urinary frequency. Dysuria might indicate a urinary tract infection. Constipation may occur throughout pregnancy due to decreased peristalsis, but it is unrelated to lightening.



Page:  291
3. A gravida 2 para 1 client in the 10th week of her pregnancy says to the nurse, “I’ve never urinated as often as I have for the past three weeks.” Which response would be most appropriate for the nurse to make?
A) “Having to urinate so often is annoying. I suggest that you watch how much fluid you are drinking and limit it.”
B) “You shouldn’t be urinating this frequently now; it usually stops by the time you’re eight weeks pregnant. Is there anything else bothering you?”
C) By the time you are 12 weeks pregnant, this frequent urination should no longer be a problem, but it is likely to return toward the end of your pregnancy.”
D) “Women having their second child generally don’t have frequent urination. Are you experiencing any burning sensations?”
Ans: C
As the uterus grows, it presses on the urinary bladder, causing the increased frequency of urination during the first trimester. This complaint lessens during the second trimester only to reappear in the third trimester as the fetus begins to descend into the pelvis, causing pressure on the bladder.



Page:  291
4. In a client’s seventh month of pregnancy, she reports feeling “dizzy, like I’m going to pass out, when I lie down flat on my back.” The nurse explains that this is due to:
A) Pressure of the gravid uterus on the vena cava
B) A 50% increase in blood volume
C) Physiologic anemia due to hemoglobin decrease
D) Pressure of the presenting fetal part on the diaphragm
Ans: A
The client is describing symptoms of supine hypotension syndrome, which occurs when the heavy gravid uterus falls back against the superior vena cava in the supine position. The vena cava is compressed, reducing venous return, cardiac output, and blood pressure, with increased orthostasis. The increased blood volume and physiologic anemia are unrelated to the client’s symptoms. Pressure on the diaphragm would lead to dyspnea.



Page:  291
5. A primiparous client is being seen in the clinic for her first prenatal visit. It is determined that she is 11 weeks pregnant. The nurse develops a teaching plan to educate the client about what she will most likely experience during this period. Which of the following would the nurse include?
A) Ankle edema
B) Urinary frequency
C) Backache
D) Hemorrhoids
Ans: B
The client is in her first trimester and would most likely experience urinary frequency as the growing uterus presses on the bladder. Ankle edema, backache, and hemorrhoids would be more common during the later stages of pregnancy.



Page:  294
6. A pregnant client in her second trimester has a hemoglobin level of 11 g/dL. The nurse interprets this as indicating which of the following?
A) Iron-deficiency anemia
B) A multiple gestation pregnancy
C) Greater-than-expected weight gain
D) Hemodilution of pregnancy
Ans: D
During pregnancy, the red blood cell count increases along with an increase in plasma volume. However, there is a greater increase in the plasma volume as a result of hormonal factors and sodium and water retention. Thus, the plasma increase exceeds the increase in RBCs, resulting in hemodilution of pregnancy, which is also called physiologic anemia of pregnancy. Changes in maternal iron levels would be more indicative of an iron-deficiency anemia. Although anemia may be present with a multiple gestation, an ultrasound would be a more reliable method of identifying it. Weight gain does not correlate with hemoglobin levels.



Page:  298
7. The nurse is discussing the insulin needs of a primaparous client with diabetes who has been using insulin for the past few years. The nurse informs the client that her insulin needs will increase during pregnancy based on the nurse’s understanding that the placenta produces:
A) hCG, which increases maternal glucose levels
B) hPL, which deceases the effectiveness of insulin
C) Estriol, which interferes with insulin crossing the placenta
D) Relaxin, which decreases the amount of insulin produced
Ans: B
hPL acts as an antagonist to insulin, so the mother must produce more insulin to overcome this resistance. If the mother has diabetes, then her insulin need would most likely increase to meet this demand. hCG does not affect insulin and glucose level. Estrogen, not estriol, is believed to oppose insulin. In addition, insulin does not cross the placenta. Relaxin is not associated with insulin resistance.



Page:  298
8. When teaching a pregnant client about the physiologic changes of pregnancy, the nurse reviews the effect of pregnancy on glucose metabolism. Which of the following would the nurse include as the underlying reason for the effect?
A) Pancreatic function is affected by pregnancy.
B) Glucose is utilized more rapidly during a pregnancy.
C) The pregnant woman increases her dietary intake.
D) Glucose moves through the placenta to assist the fetus.
Ans: D
The growing fetus has large needs for glucose, amino acids, and lipids, placing demands on maternal glucose stores. During the first half of pregnancy, much of the maternal glucose is diverted to the growing fetus. The pancreas continues to function during pregnancy. However, the placental hormones can affect maternal insulin levels. The demand for glucose by the fetus during pregnancy is high, but it is not necessarily used more rapidly. Placental hormones, not the woman’s dietary intake, play a major role in glucose metabolism during pregnancy.



Page:  307
9. When assessing a woman in her first trimester, which emotional response would the nurse most likely expect to find?
A) Ambivalence
B) Introversion
C) Acceptance
D) Emotional lability
Ans: A
During the first trimester, the pregnant woman commonly experiences ambivalence, with conflicting feelings at the same time. Introversion heightens during the first and third trimesters when the woman’s focus is on behaviors that will ensure a safe and healthy pregnancy outcome. Acceptance usually occurs during the second trimester. Emotional lability (mood swings) is characteristic throughout a woman’s pregnancy.



Page:  308
10. The nurse is assessing a pregnant woman in the second trimester. Which of the following tasks would indicate to the nurse that the client is incorporating the maternal role into her personality?
A) The woman demonstrates concern for herself and her fetus as a unit.
B) The client identifies what she must give up to assume her new role.
C) The woman acknowledges the fetus as a separate entity within her.
D) The client demonstrates unconditional acceptance without rejection.
Ans: C
Incorporation of the maternal role into her personality indicates acceptance by the pregnant woman. In doing so, the woman becomes able to identify the fetus as a separate individual. Demonstrating concern for herself and her fetus as a unit is associated with introversion and more commonly occurs during the third trimester. Identification of what the mother must give up to assume the new role occurs during the first trimester. Demonstrating unconditional acceptance without rejection occurs during the third trimester.



Page:  289
11. A woman comes to the prenatal clinic suspecting that she is pregnant, and assessment reveals probable signs of pregnancy. Which of the following would be included as part of this assessment? Select all that apply.
A) Positive pregnancy test
B) Ultrasound visualization of the fetus
C) Auscultation of a fetal heart beat
D) Ballottement
E) Absence of menstruation
F) Softening of the cervix
Ans: A, D, F
Probable signs of pregnancy include a positive pregnancy test, ballottement, and softening of the cervix (Goodell’s sign). Ultrasound visualization of the fetus, auscultation of a fetal heart beat, and palpation of fetal movements are considered positive signs of pregnancy. Absence of menstruation is a presumptive sign of pregnancy.



Page:  304
12. The nurse is teaching a pregnant woman with a prepregnancy body mass index of 26 about recommended weight gain. The nurse determines that the teaching was successful when the woman states that she should gain no more than which amount during pregnancy?
A) 35 to 40 pounds
B) 25 to 35 pounds
C) 28 to 40 pounds
D) 15 to 25 pounds
Ans: D
A woman with a body mass index of 26 is considered overweight and should gain no more than 15 to 25 pounds during pregnancy. Women with a body mass index of 18 5 to 24.9 (considered healthy weight) should gain 25 to 35 pounds. A woman with a body mass index less than 18.5 should gain 28 to 40 pounds.



Page:  302
13. A nurse strongly encourages a pregnant client to avoid eating swordfish and tilefish because these fish contain which of the following?
A) Excess folic acid, which could increase the risk for neural tube defects
B) Mercury, which could harm the developing fetus if eaten in large amounts
C) Lactose, which leads to abdominal discomfort, gas, and diarrhea
D) Low-quality protein that does not meet the woman’s requirements
Ans: B
Nearly all fish and shellfish contain traces of mercury and some contain higher levels of mercury that may harm the developing fetus if ingested by pregnant women in large amounts. Among these fish are shark, swordfish, king mackerel, and tilefish. Folic acid is found in dark green vegetables, baked beans, black-eyed peas, citrus fruits, peanuts, and liver. Folic acid supplements are needed to prevent neural tube defects. Women who are lactose-intolerant experience abdominal discomfort, gas, and diarrhea if they ingest foods containing lactose. Fish and shellfish are an important part of a healthy diet because they contain high-quality proteins, are low in saturated fat, and contain omega-3 fatty acids.



Page:  295
14. Which of the following changes in the musculoskeletal system would the nurse mention when teaching a group of pregnant women about the physiologic changes of pregnancy?
A) Ligament tightening
B) Decreased swayback
C) Increased lordosis
D) Joint contraction
Ans: C
With pregnancy, the woman’s center of gravity shifts forward, requiring a realignment of the spinal curvatures. There is an increase in the normal lumbosacral curve (lordosis). Ligaments of the sacroiliac joints and pubis symphysis soften and stretch. Increased swayback and an upper spine extension to compensate for the enlarging abdomen occur. Joint relaxation and increased mobility occur due to the influence of the hormones relaxin and progesterone.



Page:  296
15. Assessment of a pregnant woman reveals a pigmented line down the middle of her abdomen. The nurse documents this as which of the following?
A) Linea nigra
B) Striae gravidarum
C) Melasma
D) Vascular spiders
Ans: A
Linea nigra refers to the darkened line of pigmentation down the middle of the abdomen in pregnant women. Striae gravidarum refers to stretch marks, irregular reddish streaks on the abdomen, breasts, and buttocks. Melasma refers to the increased pigmentation on the face, also known as the “mask of pregnancy.” Vascular spiders are small, spiderlike blood vessels that appear usually above the waist and on the neck, thorax, face, and arms.


Ch. 21: Nursing Management of Labor and Birth at Risk



Page:  661
1. After spontaneous rupture of membranes, the nurse notices a prolapsed cord. The nurse immediately places the woman in which position?
A) Supine
B) Side-lying
C) Sitting
D) Knee–chest
Ans: D
Pressure on the cord needs to be relieved. Therefore, the nurse would position the woman in a modified Sims, Trendelenburg, or knee–chest position. Supine, side-lying, or sitting would not provide relief of cord compression.



Page:  636
2. A primigravida whose labor was initially progressing normally is now experiencing a decrease in the frequency and intensity of her contractions. The nurse would assess the woman for which condition?
A) A low-lying placenta
B) Fetopelvic disproportion
C) Contraction ring
D) Uterine bleeding
Ans: B
The woman is experiencing dystocia most likely due to hypotonic uterine dysfunction and fetopelvic disproportion associated with a large fetus. A low-lying placenta, contraction ring, or uterine bleeding would not be associated with a change in labor pattern.



Page:  661
3. The nurse would be alert for possible placental abruption during labor when assessment reveals which of the following?
A) Macrosomia
B) Gestational hypertension
C) Gestational diabetes
D) Low parity
Ans: B
Risk factors for placental abruption include preeclampsia, gestational hypertension, seizure activity, uterine rupture, trauma, smoking, cocaine use, coagulation defects, previous history of abruption, domestic violence, and placental pathology. Macrosomia, gestational diabetes, and low parity are not considered risk factors.



Page:  643
4. Assessment of a woman in labor who is experiencing hypertonic uterine dysfunction would reveal contractions that are:
A) Well coordinated
B) Poor in quality
C) Rapidly occurring
D) Erratic
Ans: D
Hypertonic contractions occur when the uterus never fully relaxes between contractions, making the contractions erratic and poorly coordinated because more than one uterine pacemaker is sending signals for contraction. Hypotonic uterine contractions are poor in quality and lack sufficient intensity to dilate and efface the cervix. Contractions of precipitous labor occur rapidly such that labor is completed in less than three hours.



Page:  636
5. A woman in labor is experiencing hypotonic uterine dysfunction. Assessment reveals no fetopelvic disproportion. Which group of medications would the nurse expect to administer?
A) Sedatives
B) Tocolytics
C) Oxytocins
D) Corticosteroids
Ans: C
For hypotonic labor, a uterine stimulant such as oxytocin may be ordered once fetopelvic disproportion is ruled out. Sedatives might be helpful for the woman with hypertonic uterine contractions to promote rest and relaxation. Tocolytics would be ordered to control preterm labor. Corticosteroids may be given to enhance fetal lung maturity for women experiencing preterm labor.



Page:  645
6. The fetus of a woman in labor is determined to be in persistent occiput posterior position. Which of the following would the nurse identify as the priority intervention?
A) Position changes
B) Pain relief measures
C) Immediate cesarean birth
D) Oxytocin administration
Ans: B
Intense back pain is associated with persistent occiput posterior position. Therefore, a priority is to provide pain relief measures. Counterpressure and backrubs may be helpful. Position changes that can promote fetal head rotation are important after the nurse institutes pain relief measures. Additionally, the woman’s ability to cooperate and participate in these position changes is enhanced when she is experiencing less pain. Immediate cesarean birth is not indicated unless there is evidence of fetal distress. Oxytocin would add to the woman’s already high level of pain.



Page:  665
7. A woman gave birth to a newborn via vaginal delivery with the use of a vacuum extractor. The nurse would be alert for which of the following in the newborn?
A) Asphyxia
B) Clavicular fracture
C) Caput succedaneum
D) Central nervous system injury
Ans: C
Use of forceps or a vacuum extractor poses the risk of tissue trauma, such as ecchymoses, facial and scalp lacerations, facial nerve injury, cephalhematoma, and caput succedaneum. Asphyxia may be related to numerous causes but it is not associated with use of a vacuum extractor. Clavicular fracture is associated with shoulder dystocia. Central nervous system injury is not associated with the use of a vacuum extractor.



Page:  656
8. A pregnant client undergoing labor induction is receiving an oxytocin infusion. Which of the following findings would require immediate intervention?
A) Fetal heart rate of 150 beats/minute
B) Contractions every 2 minutes, lasting 45 seconds
C) Uterine resting tone of 14 mm Hg
D) Urine output of 20 mL/hour
Ans: D
Oxytocin can lead to water intoxication. Therefore, a urine output of 20 mL/hour is below acceptable limits of 30 mL/hour and requires intervention. FHR of 150 beats/minute is within the accepted range of 120 to 160 beats/minutes. Contractions should occur every 2 to 3 minutes, lasting 40 to 60 seconds. A uterine resting tone greater than 20 mm Hg would require intervention.



Page:  662
9. A woman with a history of crack cocaine abuse is admitted to the labor and birth area. While caring for the client, the nurse notes a sudden onset of fetal bradycardia. Inspection of the abdomen reveals an irregular wall contour. The client also complains of acute abdominal pain that is continuous. Which of the following would the nurse suspect?
A) Amniotic fluid embolism
B) Shoulder dystocia
C) Uterine rupture
D) Umbilical cord prolapse
Ans: C
Uterine rupture is associated with crack cocaine use, and generally the first and most reliable sign is sudden fetal distress accompanied by acute abdominal pain, vaginal bleeding, hematuria, irregular wall contour, and loss of station in the fetal presenting part. Amniotic fluid embolism often is manifested with a sudden onset of respiratory distress. Shoulder dystocia is noted when continued fetal descent is obstructed after the fetal head is delivered. Umbilical cord prolapse is noted as the protrusion of the cord alongside or ahead of the presenting part of the fetus.



Page:  667
10. When assessing several women for possible VBAC, which woman would the nurse identify as being the best candidate?
A) One who has undergone a previous myomectomy
B) One who had a previous cesarean birth via a low transverse incision
C) One who has a history of a contracted pelvis
D) One who has a vertical incision from a previous cesarean birth
Ans: B
VBAC is an appropriate choice for women who have had a previous cesarean birth with a lower abdominal transverse incision. It is contraindicated in women who have a prior classic uterine incision (vertical), prior transfundal surgery, such as myomectomy, or a contracted pelvis.



Page:  663
11. A woman is to undergo an amnioinfusion. Which statement would be most appropriate to include when teaching the woman about this procedure?
A) You’ll need to stay in bed while you’re having this procedure.”
B) “We’ll give you an analgesic to help reduce the pain.”
C) “After the infusion, you’ll be scheduled for a cesarean birth.”
D) “A suction cup is placed on your baby’s head to help bring it out.”
Ans: A
An amnioinfusion involves the instillation of a volume of warmed, sterile normal saline or Ringer’s lactate into the uterus via an intrauterine pressure catheter. The client must remain in bed during the procedure. The use of analgesia is unrelated to this procedure. A cesarean birth is necessary only if the FHR does not improve after the amnioinfusion. Application of a suction cup to the head of the fetus refers to a vacuum-assisted birth.



Page:  654
12. Which finding would indicate to the nurse that a woman’s cervix is ripe in preparation for labor induction?
A) Posterior position
B) Firm
C) Closed
D) Shortened
Ans: D
A ripe cervix is shortened, centered (anterior), softened, and partially dilated. An unripe cervix is long, closed, posterior, and firm.



Page:  648
13. A woman with preterm labor is receiving magnesium sulfate. Which finding would require the nurse to intervene immediately?
A) Respiratory rate of 16 breaths per minute
B) Diminished deep tendon reflexes
C) Urine output of 45 mL/hour
D) Alert level of consciousness
Ans: B
Diminished deep tendon reflexes suggest magnesium toxicity, which requires immediate intervention. Additional signs of magnesium toxicity include a respiratory rate less than 12 breaths/minute, urine output less than 30 mL/hour, and a decreased level of consciousness.



Page:  652
14. A woman who is 42 weeks pregnant comes to the clinic. Which of the following would be most important?
A) Determining an accurate gestational age
B) Asking her about the occurrence of contractions
C) Checking for spontaneous rupture of membranes
D) Measuring the height of the fundus
Ans: A
Incorrect dates account for the majority of postterm pregnancies; many women have irregular menses and thus cannot identify the date of their last menstrual period accurately. Therefore, accurate gestational dating via ultrasound is essential. Asking about contractions and checking for ruptured membranes, although important assessments, would be done once the gestational age is confirmed. Measuring the height of the fundus would be unreliable because after 36 weeks, the fundal height drops due to lightening and may no longer correlate with gestational weeks.



Page:  666
15. After teaching a couple about what to expect with their planned cesarean birth, which statement indicates the need for additional teaching?
A) “Holding a pillow against my incision will help me when I cough.”
B) I’m going to have to wait a few days before I can start breast-feeding.”
C) “I guess the nurses will be getting me up and out of bed rather quickly.”
D) “I’ll probably have a tube in my bladder for about 24 hours or so.”
Ans: B
Typically, breast-feeding is initiated early as soon as possible after birth to promote bonding. The woman may need to use alternate positioning techniques to reduce incisional discomfort. Splinting with pillows helps to reduce the discomfort associated with coughing. Early ambulation is encouraged to prevent respiratory and cardiovascular problems and promote peristalsis. An indwelling urinary catheter is typically inserted to drain the bladder. It usually remains in place for approximately 24 hours.


Ch. 31: Health Assessment of Children



Page:  957
1. The parents of a 2-day-old girl are concerned because her feet and hands are slightly blue. How should the nurse respond?
A) “Your daughter has acrocyanosis; this is causing her blue hands and feet.”
B) “Let’s watch her carefully to make sure she does not have a circulatory problem.”
C) This is normal; her circulatory system will take a few days to adjust.”
D) “This a vaso-motor response caused by cooling or warming.”
Ans: C
The nurse should tell the parents that this is normal and that the baby’s circulatory system is adjusting to extra-uterine life. Using the technical term “acrocyanosis” would most likely scare the parents. Telling the parents that the child may have a circulatory problem is inaccurate as this is a normal variation. Acrocyanosis and the mottling caused by cooling and warming are two different variations.



Page:  960
2. A nurse is assessing the fontanels of a crying newborn and notes that the posterior fontanel pulsates and briefly bulges. What do these findings indicate?
A) Increased intracranial pressure
B) Overhydration
C) Dehydration
D) A normal finding
Ans: D
It is common to see the fontanel pulsate or briefly bulge if a baby cries. Overhydration or increased cranial pressure would cause a persistent bulging. Dehydration would cause the fontanel to be sunken.



Page:  949
3. The nurse is preparing to take a tympanic temperature reading of a 4-year-old. To get an accurate reading, what does the nurse need to do?
A) Pull the earlobe back and down.
B) Direct the infrared sensor at the tympanic membrane.
C) Pull the earlobe down and forward.
D) Remove any visible cerumen from inside the ear canal.
Ans: B
The accuracy of tympanic temperature reading is dependent upon appropriate technique. The nurse needs to be sure to direct the infrared sensor at the tympanic membrane. Since the child is over the age of 3, the earlobe does not need to be pulled back and down. The nurse would not remove earwax from inside the ear canal.



Page:  950
4. The nurse is assessing the heart rate of a healthy 13-month-old child. The nurse knows to auscultate which of the following sites to obtain an accurate assessment?
A) Radial pulse
B) Brachial pulse
C) Apical pulse at the third or fourth intercostal space
D) Apical pulse at the fourth or fifth interspace at the midclavicular line
Ans: C
For children younger than 2 years of age, the nurse should auscultate the apical pulse with the stethoscope at the point of maximum intensity just above and outside of the left nipple at the third or fourth intercostal space. The radial pulse is difficult to palpate accurately on children less than 2 years of age because the blood vessels lie so close to the skin surface and are easily obliterated. The brachial pulse is not the best point of auscultation. The point of maximum intensity (PMI) is heard best at the fourth or fifth intercostal space at the midclavicular line beginning around 7 years of age.



Page:  960
5. The nurse is assessing the neck of an 8-year-old child with Down syndrome. Which of the following findings would the nurse expect during the examination?
A) Webbing
B) Excessive neck skin
C) Lax neck skin
D) Shortened neck
Ans: C
Lax neck skin may occur with Down syndrome. Webbing or excessive neck skin folds may be associated with Turner syndrome. A shortened neck is expected in a child under age 4.



Page:  959
6. The nurse is conducting a routine health assessment of a 3-month-old boy and notices a flat occiput. The nurse provides teaching and emphasizes the importance of “tummy time.” Which of the following responses by the mother indicates a need for further teaching?
A) He must be positioned on his tummy as much as possible.”
B) “I need to watch him during his tummy time.”
C) “I need to change his head position while he is in an upright chair.”
D) “His head has flattened due to the pressure of his head position.”
Ans: A
The nurse needs to emphasize that “tummy time” should occur only when the child is observed and awake; the baby should still sleep on his back. The other statements are correct.



Page:  953
7. The nurse is measuring the blood pressure of a 12-year-old boy with an oscillometric device. The boy’s reading is greater than the 90th percentile for gender and height. What is the appropriate nursing action?
A) Repeat the reading with the oscillometric device.
B) Repeat the blood pressure reading using auscultation.
C) Measure the blood pressure in all four extremities.
D) Measure the blood pressure with a Doppler.
Ans: B
The nurse should repeat the reading using auscultation. The nurse should not use the Doppler ultrasound method in this circumstance. The nurse would measure the blood pressure in all four extremities in a child presenting with cardiac complaints.



Page:  959
8. The nurse is inspecting the fingernails of an 18-month-old girl. Which of the following findings indicates chronic hypoxemia?
A) Nails that curve inward
B) Clubbing of the nails
C) Nails that curve outward
D) Dry, brittle nails
Ans: B
Clubbing of the nails indicates chronic hypoxemia, related to either respiratory or cardiac disease. Nails that curve inward or outward may be hereditary or linked with injury, infection, or iron deficiency anemia. Dry, brittle nails may indicate a nutritional deficiency.



Page:  951
9. The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child’s heart rate will be in which of the following ranges?
A) 120 to 160 bpm
B) 80 to 130 bpm
C) 75 to 120 bpm
D) 80 to 150 bpm
Ans: C
The normal range for a healthy school-age child would be 75 to 120 bpm. The ranges for a healthy infant would be 80 to 150, a healthy newborn would be 120 to 160, and a healthy preschooler would be 80 to 130.



Page:  951
10. The nurse is using pulse oximetry to measure oxygen saturation in a 3-year-old girl. The nurse understands that falsely high readings may be associated with which situation or condition?
A) A non-secure connection
B) Cold extremities
C) Hypovolemia
D) Anemia
Ans: D
Falsely high readings may be associated with anemia. Falsely low readings may be associated with cold extremities, hypovolemia, and a non-secure connection.



Page:  945
11. Which of the following would be least effective in gaining the cooperation of a toddler during a physical examination?
A) Tell the child that another child the same age wasn’t afraid.
B) Allow the child to touch and hold the equipment when possible.
C) Permit the child to sit on the parent’s lap during the examination.
D) Offer immediate praise for holding still or doing what was asked.
Ans: A
Toddlers are egocentric, and telling the toddler how well another child behaved or cooperated probably will not help gain this child’s cooperation. Allowing the child to touch and hold the equipment, permitting the child to sit on the parent’s lap during the exam, and offering praise immediately for cooperating would foster cooperation.



Page:  949
12. A mother brings her 3-1/2-year-old daughter to the emergency department because the child has been vomiting and having diarrhea for the past 36 hours. When assessing this child’s temperature, which method would be least appropriate?
A) Oral
B) Tympanic
C) Rectal
D) Axillary
Ans: C
Obtaining the child’s temperature via the rectal route would be least appropriate because the child has diarrhea, and insertion of the thermometer might traumatize the rectal mucosa. Additionally, the rectal route is highly invasive and a child of this age fears body invasion. Using the oral route might be problematic due to the child’s age and inability to cooperate, especially in light of the child’s vomiting. However, it would not be as dangerous as obtaining a rectal temperature. The tympanic or axillary method would be the most appropriate method.



Page:  956
13. Assessment reveals that a child weighs 73 lbs and is 4 ft 1 in tall. The nurse calculates this child’s body mass index as:
A) 19.1
B) 20.7
C) 21.4
D) 24.5
Ans: C
Body mass index is determined by dividing the child’s weight (in pounds) by the child’s height (in inches) squared and then multiplying this figure by 703. Thus, 73 lbs divided by (49 inches ´ 49 inches) equals 0.0304 multiplied by 703 equals 21.37 or 21.4.



Page:  950
14. The nurse is preparing to assess the pulse of an 18-month-old. Which pulse would be most difficult for the nurse to palpate?
A) Radial
B) Brachial
C) Pedal
D) Femoral
Ans: A
In a child less than 2 years of age, the radial pulse is very difficult to palpate, whereas the pedal, brachial, and femoral pulses are usually easily palpated.



Page:  969
15. While auscultating the heart of a 5-year-old child, the nurse notes a murmur that is soft and quiet and heard each time the heart is auscultated. The nurse documents this finding as which of the following?
A) Grade 1
B) Grade 2
C) Grade 3
D) Grade 4
Ans: B
A grade 2 murmur is soft and quiet and is heard each time the chest is auscultated. A grade 1 murmur is barely audible and is heard at some times and not at other times. A grade 3 murmur is audible with intermediate intensity. A grade 4 murmur is audible and accompanied by a palpable thrill.


Ch. 41: Nursing Care of the Child with a Gastrointestinal Disorder



Page:  1361
1. The nurse is teaching the mother of a 4-year-old boy with a history of impaction to administer enemas at home. Which of the following responses from the mother indicates a need for further teaching?
A) I should position him on his abdomen with his knees bent.”
B) “He will require 250 to 500 mL of enema solution.”
C) “I should wash my hands and then put on gloves.”
D) “He should retain the solution for 5 to 10 minutes.”
Ans: A
A 4-year-old child should lie on his or her left side with the right leg flexed toward the chest. An infant or toddler is positioned on the abdomen. A toddler or preschooler should receive approximately 250 to 500 mL of enema solution and retain the enema for 5 to 10 minutes. The caregiver should wash his or her hands and then apply gloves.



Page:  1368
2. The nurse is taking a health history of an 11-year-old girl with recurrent abdominal pain. Which of the following responses would indicate irritable bowel syndrome?
A) I always feel better after I have a bowel movement.”
B) “I don’t take any medicine right now.”
C) “The pain comes and goes.”
D) “The pain does not wake me up in the middle of the night.”
Ans: A
In cases of irritable bowel syndrome, the pain may be relieved by defecation. Not taking any medicines and pain that comes and goes and does not wake the child during the night are all relevant findings pertinent to recurrent abdominal pain.



Page:  1363
3. The nurse is caring for a 3-year-old with short bowel syndrome as a result of trauma to the small intestine. The girl’s mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. How should the nurse respond?
A) I will help you become an expert on your daughter’s care.”
B) “You must learn how to care for your daughter at home.”
C) “You really need the support of your husband.”
D) “There is a lot to learn, and you need a positive attitude.”
Ans: A
The nurse needs to empower families to become the experts on their child’s needs and condition via education and participation in care. The most positive approach is to let the mother know the nurse will support her and help her become an expert on her daughter’s care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude would not be helpful. Telling her that she needs the support of her husband is irrelevant and unhelpful.



Page:  1364
4. The nurse is conducting a physical examination of a child with suspected Crohn’s disease. Which of the following findings would the nurse interpret as being highly suspicious of this disorder?
A) Normal growth patterns
B) Perianal skin tags or fissures
C) Precocious puberty
D) Abdominal tenderness
Ans: B
Perianal skin tags and/or fissures are highly suspicious of Crohn’s disease. Abdominal tenderness is also common to Crohn’s disease but is seen with many other conditions as well. Normal growth patterns would not point to Crohn’s disease because of problems with nutrient absorption. Delayed sexual development is associated with Crohn’s disease.



Page:  1337
5. The nurse is caring for an infant with a temporary ileostomy. As part of the nursing plan of care, the nurse monitors for skin breakdown around the stoma. If redness occurs, which action would be most appropriate to promote healing and prevent further skin breakdown?
A) Cleaning the area well with a scented diaper wipe
B) Applying a barrier/healing cream or paste on the skin
C) Using a barrier wafer (such as Stomahesive) to attach the appliance
D) Sanitizing the area with an alcohol wipe after each diaper change
Ans: B
The nurse should use barrier/healing cream or paste on the skin around the stoma to promote healing and to prevent further skin breakdown. Diaper wipes that contain fragrance or alcohol can sting if used on non-intact skin and can worsen skin breakdown. The barrier wafer would be helpful but does not address the skin breakdown.



Page:  1337
6. The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would most likely elicit the child’s cooperation?
A) “Can you cough for me, please?”
B) “You must blow in this or you might get pneumonia.”
C) “If you don’t try, I will have to get the doctor.”
D) Can you blow this cotton ball across the tray?”
Ans: D
Children are more likely to cooperate with interventions if play is involved. Encourage deep breathing by playing games. Asking the boy to cough is less likely to engage him. Telling the child he might get pneumonia is not age-appropriate and unhelpful. Threatening to call the doctor is unhelpful and inappropriate. Remember, however, that the incentive spirometer works on the principle of the amount of air inhaled, not exhaled. Having the child take a deep breath prior to blowing the cotton ball is a beginning step.



Page:  1333
7. A nurse is caring for a 14-year-old girl scheduled for a barium swallow/upper GI series. Which of the following would the priority?
A) Screen the girl for pregnancy.
B) Remind her to drink fluids after the procedure.
C) Initiate the ordered bowel prep.
D) Remind the girl that her stools may be light-colored.
Ans: A
Females of reproductive age must be screened for pregnancy prior to the test because radiography is used. A bowel prep is not necessary for a barium swallow/upper GI. The reminders about fluids and light-colored stools are appropriate but not the first priority.



Page:  1345
8. The nurse has developed a plan of care for a 12-month-old hospitalized with dehydration as a result of rotavirus. Which intervention would the nurse include in the plan of care?
A) Encouraging the infant to drink fruit juice
B) Offering Kool-Aid or popsicles as tolerated
C) Encouraging milk products to boost calorie intake
D) Maintaining the intravenous fluid rate as ordered
Ans: D
The nurse should maintain the intravenous line and administer the IV fluid as ordered to maintain fluid volume. High-carbohydrate fluids like fruit juice, Kool-Aid, and popsicles should be avoided as they are low in electrolytes, increase simple carbohydrate consumption, and can decrease stool transit time. Milk products should be avoided during the acute phase of illness as they may worsen diarrhea.



Page:  1341
9. The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breast-feeding the baby after surgery and wonders if it will be possible. Which response by the nurse would be most appropriate?
A) “There is a good chance that you will be able to breast-feed almost immediately.”
B) Breast-feeding is likely to be possible, but check with your surgeon.”
C) “After the suture line heals, breast-feeding can resume.”
D) “We will have to wait and see what happens after the surgery.”
Ans: B
Postoperatively, some surgeons allow breast-feeding to be resumed almost immediately. The nurse should advise the woman to check with the surgeon. Telling the mother that she has to wait until the suture line heals may be inaccurate. Telling her to wait and see does not answer her question.



Page:  1369
10. The school nurse is working with a 10-year-old girl with recurrent abdominal pain. The girl’s teacher has been less than understanding about her frequent absences and trips to the nurse’s office. Which response to the girl’s teacher would be most appropriate?
A) “Be patient; she is trying some new medication.”
B) The pain she is having is real.”
C) “The family is working towards improvement.”
D) “Please do not add to this family’s stress.”
Ans: B
It is important to educate the teacher that this recurrent abdominal pain is a true pain and is not “just in her mind.” Telling the teacher not to add to the family’s stress or that they are working towards improvement does not teach. The nurse must have the permission of the family to discuss the girl’s medication.



Page:  1332
11. When examining the abdomen of a child, which technique would the nurse use last?
A) Auscultation
B) Percussion
C) Palpation
D) Inspection
Ans: C
Palpation should be the last part of the abdominal examination. Inspection, auscultation, and percussion should be done before palpation.



Page:  1345
12. Which finding would lead the nurse to suspect that a child is experiencing moderate dehydration?
A) Dusky extremities
B) Tenting of skin
C) Sunken fontanels
D) Hypotension
Ans: C
A child with moderate dehydration would exhibit sunken fontanels. Severe dehydration would be characterized by dusky extremities, skin tenting, and hypotension.



Page:  1345
13. The nurse is determining maintenance fluid requirements for a child who weighs 25 kg. How much fluid would the child need per day?
A) 1,560 mL
B) 1,600 mL
C) 1,650 mL
D) 1,700 mL
Ans: B
Using the following formula of 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, and then 20 mL/kg for the remaining kg, the child would require (100 ´ 10) + (50 ´ 10) + (20 ´ 5) = 1,000 + 500 + 100 = 1,600 mL in 24 hours.



Page:  1368
14. The parents of a child diagnosed with celiac disease ask the nurse what types of food they can offer their child. Which of the following would the nurse include in the teaching plan?
A) Frozen yogurt
B) Rye bread
C) Creamed spinach
D) Fruit juice
Ans: D
For the child with celiac disease, foods containing gluten such as frozen yogurt, rye bread, and creamed vegetables should be avoided. Fruit juice would be an appropriate suggestion in a gluten-free diet.



Page:  1353
15. In a child with intussusception, the nurse would describe the stools as:
A) Greasy
B) Clay-colored
C) Currant jelly-like
D) Bloody
Ans: C
The child with intussusception often exhibits currant jelly-like stools that may or may not be positive for blood. Greasy stools are associated with celiac disease. Clay-colored stools are observed with biliary atresia. Bloody stools can be seen with several

gastrointestinal disorders, such as inflammatory bowel disease.


Ch. 51: Nursing Care of the Child with a Cognitive or Mental Health Disorder



Page:  1713
1. The nurse is teaching the mother of a 12-year-old boy about the risk factors for drug and alcohol abuse. Which of the following responses from the mother indicates a need for further teaching?
A) “A family history of alcoholism is a risk factor for substance abuse.”
B) Just because his friends are experimenting does not mean he will.”
C) “If my husband or I have a substance abuse problem it could increase his risk.”
D) “Negative life events are a potential risk factor.”
Ans: B
The nurse needs to emphasize that having peers who abuse substances is a risk factor associated with substance abuse and increases the chances that the child will also experiment. The other statements are correct.



Page:  1708
2. The nurse is caring for an adolescent girl with anorexia nervosa. Which of the following findings would warrant hospitalization rather than outpatient treatment?
A) Weight gain of 1/2 pound per week
B) Food refusal
C) Body mass index of 18
D) Soft sparse body hair with dry, sallow skin
Ans: B
Food refusal, severe weight loss, unstable vital signs, arrested pubertal development, and the need for enteral nutrition warrant hospitalization. Soft, sparse body hair and dry, sallow skin are signs of anorexia but do not warrant hospitalization. A weight gain of a half-pound per week indicates progress toward therapeutic goals. A body mass index of 18 is on the low end of the normal range of body mass.



Page:  1710
3. The nurse is caring for an adolescent girl with a suspected anxiety disorder. The girl states that she is constantly double-checking that she has unplugged her curling iron and must make sure that everything is in perfect order in her room before she leaves the house. The nurse suspects which of the following?
A) Generalized anxiety disorder
B) Post-traumatic stress disorder
C) Social phobia
D) Obsessive-compulsive disorder
Ans: D
Obsessive-compulsive disorder is characterized by compulsion (repetitive behaviors such as cleaning, washing, checking something) to reduce anxiety about obsessions (unwanted and intrusive thoughts). Post-traumatic stress disorder is an anxiety disorder that occurs after a child is subjected to a traumatic event, later experiencing physiological arousal when a stimulus triggers memories of the event. Generalized anxiety disorder is characterized by unrealistic concerns over past behavior, future events, and personal competency. Social phobia is characterized by a persistent fear of public speaking, using public restrooms, or eating in front of others.



Page:  1707
4. The nurse is caring for a 7-year-old with Tourette’s syndrome. The nurse is careful to assess for which of the following comorbid conditions?
A) Depression
B) Anxiety disorder
C) Attention-deficit/hyperactivity disorder
D) Asperger’s syndrome
Ans: C
Attention-deficit/hyperactivity disorder and obsessive-compulsive disorders occur in 90% of children with Tourette’s syndrome. Depression, anxiety disorder, and Asperger’s syndrome are not typical comorbid conditions associated with Tourette’s syndrome.



Page:  1701
5. A nurse is caring for a 10-year-old boy with a nursing diagnosis of disturbed thought processes related to anxiety. What is the priority nursing intervention to help improve thought processes?
A) Adjust your communication style based on the child’s cues
B) Provide validation of the child’s thoughts and feelings
C) Perform an age-appropriate mental status examination
D) Establish a daily routine
Ans: C
The nursing priority is to perform an age-appropriate mental status examination to determine the extent of altered thinking. This would open a dialogue and prove a baseline for further assessment and intervention. The other actions are important, but the priority is to determine the extent of altered thinking.



Page:  1704
6. The nurse is caring for a 3-year-old boy whose parents are concerned that he is exhibiting signs of cognitive delays. Which of the following statements by the parents would indicate autism spectrum disorder rather than mental retardation?
A) “He is not speaking in complete sentences.”
B) “We can understand a lot of what he says, but no one else can.”
C) He seems to be speaking less and less.”
D) “He can’t sit still for a short story.”
Ans: C
Regression or the loss of previously acquired skills points to autism rather than mental retardation. The other statements are indicative of mental retardation.



Page:  1697
7. A nurse is caring for a 5-year-old girl with depression. She is having difficulty coping with her feelings of sadness and fear, which stem from her parents’ recent divorce. The girl has been prescribed antidepressant medication, but the mother thinks the girl would benefit from therapy. The nurse refers the mother to a therapist who specializes in which of the following types of therapy?
A) Individual therapy
B) Play therapy
C) Behavioral therapy
D) Hypnosis
Ans: B
Play therapy is designed to change emotional status and encourages the child to act out feelings of sadness, fear, hostility, or anger. It is particularly beneficial for the younger child. Play therapy, rather than individual therapy, is recommended for the younger child. Hypnosis promotes deep relaxation, which is not the therapeutic goal for this child. Behavioral therapy is used to encourage appropriate behavior and would not address the girl’s sadness.



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8. The nurse is caring for a 13-year-old boy with a history of inappropriate behavior. Which of the following statements by the mother would indicate oppositional defiant disorder rather than conduct disorder?
A) He has frequent temper tantrums.”
B) “He was pulling the neighbor’s dog around by his leash.”
C) “He is constantly lying to me.”
D) “He has stolen hundreds of dollars from my purse.”
Ans: A
Frequent temper tantrums point to oppositional defiant disorder rather than conduct disorder. Cruelty to animals, excessive lying, and stealing point to conduct disorder.



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9. The nurse is caring for a 5-year-old. The child’s mother reports that he is extremely sensitive to sounds that most people do not notice and that he prefers complete silence. She explains that the boy is resisting going to school due the noise and commotion. The boy will wear only 100% cotton clothing with all of the tags cut out. The nurse suspects which of the following?
A) Anxiety disorder
B) Sensory integration dysfunction
C) Depression
D) Obsessive-compulsive disorder
Ans: B
Sensory integration dysfunction results in overreaction to different textures and hypersensitivity or hyposensitivity to sensory input. The boy’s sensitivities to sound and clothing do not point to anxiety disorder, depression, or obsessive-compulsive disorder.



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10. The nurse is caring for a child with bipolar disorder. The child is taking lithium as ordered. The parents inquire about the potential side effects. How should the nurse respond?
A) This medication may cause polyuria, polydipsia, tremor, nausea, weight gain, and diarrhea.”
B) “This medication may cause decreased appetite and difficulty sleeping.”
C) “Side effects include dry mouth, urinary retention, and constipation.”
D) “This medication can cause anticholinergic effects such as blurred vision, constipation, dry mouth, and urinary difficulties.”
Ans: A
The nurse needs to explain that the potential side effects of lithium include polyuria, polydipsia, tremors, nausea, weight gain, and diarrhea. Decreased appetite and difficulty sleeping are associated with psychostimulants. Anticholinergic effects are often associated with tricyclic antidepressants as well as alpha-agonist antihypertensive agents such as clonidine.



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11. A child with ADHD is prescribed long-acting methylphenidate. Which of the following would the nurse include when teaching the child and his parents about this drug?
A) “Give the drug three times a day: morning, mid-day, and after school.”
B) “This drug may cause drowsiness, so be careful when doing things.”
C) “Some increase in appetite may occur, so watch how much you eat.”
D) Take this drug every day in the morning when you wake up.”
Ans: D
Long-acting methylphenidate is administered once daily in the morning, whereas the other forms are given three times a day. The drug typically causes difficulty sleeping and decreased appetite.



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12. Which of the following is the most sensitive indicator of intellectual disability?
A) History of seizures
B) Preterm birth
C) Vision deficit
D) Language delay
Ans: D
Due to the extent of cognition required to understand and produce speech, the most sensitive early indicator of intellectual disability is delayed language development. A history of seizures, preterm birth, and vision deficit may be associated with intellectual disability but are not the most sensitive indicators.



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13. A school-age child diagnosed with depression is receiving antidepressant therapy. The nurse would instruct the parents to notify the physician immediately if the child demonstrates which of the following?
A) Loss of interest
B) Gastric upset
C) Sedation
D) Urinary retention
Ans: A
Children taking antidepressants are at risk for the development of presuicidal behavior, which may be indicated by a loss of interest or pleasure. Gastric upset, sedation, and urinary retention may or may not occur, but none of these would be as important to report as the potential for self-harm.



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14. Which of the following assessment findings would be least suggestive of child abuse?
A) Consistent delays in seeking treatment for the child’s injuries
B) Frequent changes in history information with visits
C) Injuries that are inconsistent with the reported traumatic event
D) Sexual behavior that correlates with child’s developmental age
Ans: D
Sexual behavior that correlates with the child’s developmental age would be appropriate and not an indicator of child abuse. A delay in seeking medical treatment, a history that changes over time, or a history of trauma that is inconsistent with the observed injury all suggest child abuse.



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15. Which of the following would lead the nurse to suspect that an adolescent has bulimia?
A) Body mass index less than 17
B) Calluses on back of knuckles
C) Nail pitting
D) Bradycardia
Ans: B
The adolescent with bulimia would exhibit calluses on the back of the knuckles and split fingernails and would be of normal weight or slightly overweight. A body mass index of 17, nail pitting, and bradycardia would suggest anorexia.