Sample Chapter

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Safe Maternity Pediatric Nursing Care By Palmer Coats – Test Bank 

 

 

Bonus Chapter 1: Introduction to QSEN

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which is the priority when providing nursing care?

1) Implementing evidence-based practice
2) Providing patient-centered care
3) Implementing safe practice
4) Providing advocacy

 

 

____    2.   Which is a result of the Institute of Medicine’s (IOM’s) report addressing quality and safety issues in health care?

1) The Quality and Safety Education for Nurses (QSEN) initiative
2) The American Nurses Association (ANA) Code of Nursing Ethics
3) The National League for Nurses (NLN) Centers of Excellence in Nursing Education
4) The American Association of Colleges of Nursing (AACN) Essentials in Nursing Practice

 

 

____    3.   Which term is used when implementing patient-centered care in the maternal-newborn and pediatric settings?

1) Culturally sensitive care
2) Evidence-based practice
3) Family-centered care
4) Age-appropriate care

 

 

____    4.   Which is a core concept in providing patient-centered care?

1) Advocacy
2) Safety
3) Collaboration
4) Teamwork

 

 

____    5.   Which should the nurse evaluate in himself/herself when implementing patient-centered care?

1) Personal values
2) Level of education
3) Use of research
4) Family dynamics

 

 

____    6.   Which is an essential skill for a nurse who is a member of a health-care team?

1) Advocacy
2) Assessment
3) Spirituality
4) Communication

 

 

____    7.   The maternal-newborn nurse works with a registered nurse and a nurse’s aide. Which type of team is this nurse a member of according to current data?

1) Intraprofessional
2) Interprofessional
3) Multidisciplinary
4) Allied health

 

 

____    8.   The nurse is a member of an interprofessional team. Which observed behavior by another member of the team could adversely affect collaboration?

1) A physician who reviews the nurse’s documentation prior to prescribing a new medication
2) A registered nurse who updates the physical therapist on a patient’s progress with ambulation
3) A licensed practical nurse who neglects to notify the charge nurse regarding abnormal vital signs
4) An unlicensed assistive personnel who asks for assistance with a delegated task

 

 

____    9.   Which action should the nurse implement to remain up-to-date regarding best patient practices?

1) Reviewing a skill in a textbook on the unit
2) Completing annually required competencies
3) Attending a conference offering continuing education credits
4) Asking a seasoned nurse to act as a professional mentor

 

 

____  10.   The nurse is asked to participate on a quality improvement (QI) committee related to hospital-acquired infections. Which initial action should the nurse take in preparation for the meeting?

1) Review current data on the subject
2) Conduct a review of the literature to determine best practices
3) Edit unit policies related to infection control and prevention
4) Plan an in-service to educate staff on the current issue

 

 

____  11.   Which electronic health record (EHR) tool should the nurse use to include evidence-based interventions in the patient’s plan of care?

1) Alerts related to abnormal test results
2) Clinical decision support tool
3) Multiuser access in real time
4) Storage of collected data

 

 

____  12.   The nurse is asked during a job interview to state a prerequisite skill in the QSEN competency related to informatics. Which response by the nurse reflects correct understanding?

1) “An advanced practice degree is considered a prerequisite skill in the QSEN competencies.”
2) “Licensure as a practical nurse is a prerequisite skill in the QSEN competencies.”
3) “Basic computer literacy is considered a prerequisite skill in the QSEN competencies.”
4) “Licensure as a registered nurse is a prerequisite skill in the QSEN competencies.”

 

 

____  13.   Which health-care provider is the last line of defense between a patient and a medication error?

1) Nurse
2) Surgeon
3) Physician
4) Pharmacist

 

 

____  14.   The nurse makes a medication error during a busy shift on the unit. Which response by the nurse manager reflects “just culture”?

1) Placing the nurse on administrative leave
2) Recommending that the nurse’s job be terminated
3) Encouraging the nurse to complete an incident report
4) Making a public announcement about the error during shift report

 

 

____  15.   Which nursing action enhances patient safety while making it harder to do the wrong thing?

1) Creating independent checks
2) Learning from defects
3) Using evidence-based practice
4) Standardizing work when possible

 

 

____  16.   Which nursing action reflects the simple rules of a 21st century health-care system?

1) Controlling the delivery of patient care
2) Including the patient in the delivery of care
3) Basing patient care on the current visit only
4) Basing patient interventions on clinical experience

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which QSEN competencies should be evaluated during performances reviews? (Select all that apply.)

1) Communication
2) Infection control
3) Patient-centered care
4) Evidence-based practice
5) Teamwork and collaboration

 

 

____  18.   Which are core concepts related to the implementation of patient-centered nursing care? (Select all that apply.)

1) Respect
2) Dignity
3) Advocacy
4) Participation
5) Collaboration

 

 

____  19.   Which patient characteristics should the nurse consider when planning patient-centered care? (Select all that apply.)

1) Knowledge
2) Values
3) Experiences
4) Diagnoses
5) Surgeries

 

 

____  20.   Which are core concepts the nurse should exhibit in order to meet the QSEN competency of teamwork and collaboration? (Select all that apply.)

1) Calculation
2) Cooperation
3) Coordination
4) Classification
5) Communication

 

Bonus Chapter 2: Cultural Competency in Maternity and Pediatric Care

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term should the nurse use to describe the display of culturally appropriate behaviors?

1) Cultural awareness
2) Cultural sensitivity
3) Diversity
4) Worldview

 

 

____    2.   Which term should the nurse use to describe developing cultural sensitivity?

1) Cultural awareness
2) Cultural competence
3) Diversity
4) Worldview

 

 

____    3.   Which nursing action is inappropriate when providing safe and effective nursing care?

1) Stereotyping a patient on the basis of ethnicity
2) Using a medical interpreter for a patient who does not speak English
3) Asking the patient how culture impacts his or her medical decisions
4) Monitoring drug effectiveness on the basis of race and gender

 

 

____    4.   Which action accounts for a patient’s cultural background when providing safe and effective nursing care in the maternal-newborn environment?

1) Assuming parents of a newborn male will want a circumcision on the basis of religious preference
2) Engaging the services of a medical interpreter for patients who speak little English
3) Deciding not to teach a pregnant patient methods to decrease risk for hypertension because of ethnicity
4) Telling a patient the scheduled appointment time is 30 minutes earlier because of listed ethnicity

 

 

____    5.   For which patient population noted to have problems accessing care for one-third of the core measures of health should the nurse focus health promotion activities within the community?

1) African Americans
2) Caucasian Americans
3) Alaskan Natives
4) American Indians

 

 

____    6.   Which is a noted issue for minorities who receive care from nurses?

1) Lack of empathy
2) Poor communication
3) Stereotypical treatment
4) Inappropriate teaching strategies

 

 

____    7.   Which question should the nurse ask to assess social factors that may impact a patient’s health status or function?

1) “What is the air quality?”
2) “Is health care available and affordable?”
3) “Was there exposure to disease or illness?”
4) “Is care provided or partially paid for by legislative processes?”

 

 

____    8.   Which question should the nurse ask to assess environmental factors that may impact a patient’s health status or function?

1) “What is the air quality?”
2) “Is health care available and affordable?”
3) “Was there exposure to disease or illness?”
4) “Is care provided or partially paid for by legislative processes?”

 

 

____    9.   Which question should the nurse ask to assess economic factors that may impact a patient’s health status or function?

1) “What is the air quality?”
2) “Is health care available and affordable?”
3) “Was there exposure to disease or illness?”
4) “Is care provided or partially paid for by legislative processes?”

 

 

____  10.   Which question should the nurse ask to assess political factors that may impact a patient’s health status or function?

1) “What is the air quality?”
2) “Is health care available and affordable?”
3) “Was there exposure to disease or illness?”
4) “Is care provided or partially paid for by legislative processes?”

 

 

____  11.   Which action by the nurse is appropriate when conducting a cultural assessment using an approved tool?

1) Allowing a family member to translate the tool if the patient does not speak English
2) Using the tool as a guide when asking the patient questions during the health history
3) Telling the patient that the tool must be implemented or care cannot be provided
4) Refusing to use the tool before appropriate training for patient implementation is received

 

 

____  12.   Which is the priority nursing action when providing care to a patient who would like to use a home remedy as part of the prescribed treatment?

1) Telling the patient that the remedy cannot be used until the provider approves it
2) Asking the patient’s family to discourage the use of the remedy
3) Imploring the patient to share information about the remedy, such as the ingredients
4) Stating the hospital policy related to the use of home remedies

 

 

____  13.   The nurse is providing care to a family with an unfamiliar cultural background. The family does not speak English, and the nurse is awaiting the arrival of a medical translator to assist with the admission assessment. Which action by the nurse is appropriate in this situation?

1) Removing the children from the room
2) Asking the charge nurse to reassign the family
3) Researching the family’s culture and common practices
4) Using nonverbal communication strategies to ask the family to be quiet

 

 

____  14.   Which nursing action enhances respectful and culturally sensitive communication?

1) Directing questions at the interpreter during the assessment process
2) Researching the cultures that the health-care organization is likely to serve
3) Telling the patient that the suggested home remedy will not be included in the plan of care
4) Asking the patient’s child to act as an interpreter during the discharge teaching process

 

 

____  15.   Which action by the nurse is appropriate when researching information related to a patient’s culture?

1) Using Google to locate information
2) Posting a Facebook status that asks friends and family members to provide information
3) Asking coworkers on LinkedIn to provide information
4) Accessing articles about the culture via PubMed

 

 

____  16.   The nurse is providing discharge teaching to a patient who does not speak English. Which action by the nurse is appropriate when providing reference materials to the patient?

1) Having the interpreter write the information in a notebook for the patient to take home
2) Asking the patient’s family to take notes during the teaching session
3) Accessing brochures and pamphlets that are written in the patient’s native language
4) Telling the patient to Google the information after discharge

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which resources should the nurse use to locate information related to best practices when providing care to patients who are from a different culture? (Select all that apply.)

1) The Joanna Briggs Institute
2) Cochrane Collection
3) Cumulative Index to Nursing and Allied Health Literature
4) Medscape
5) PubMed

 

 

____  18.   Which resources may be recommended to maternal-newborn patients to facilitate continuity of care after hospital discharge? (Select all that apply.)

1) Women, Infants, and Children (WIC)
2) Low-cost transportation
3) Community health fairs
4) Mass media
5) Technology

 

 

____  19.   Which factors should the nurse consider when conducting a cultural assessment? (Select all that apply.)

1) Social
2) Economic
3) Physical
4) Environmental
5) Psychological

 

 

____  20.   Which skills should the nurse possess in order to conduct an effective cultural assessment? (Select all that apply.)

1) Wound
2) Communication
3) Interview
4) Observation
5) IV

 

 

 

Bonus Chapter 3: Women’s Health Promotion Across the Life Span

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A patient is prescribed a hysterosalpingography and asks the nurse, “What does this mean?” Which response by the nurse is most appropriate?

1) “It is a surgical procedure to remove endometriosis.”
2) “It is a blood test to determine hormonal abnormalities.”
3) “It is a pelvic ultrasound to visualize the reproductive organs.”
4) “It is an x-ray with dye used to visualize the uterus and fallopian tubes.”

 

 

____    2.   Which is the most common cause of amenorrhea, which the nurse should include in a teaching session for women within the community?

1) Cancer
2) Pregnancy
3) Weight loss
4) Weight gain

 

 

____    3.   Which action should the nurse anticipate when providing care to a patient who is experiencing severe dysmenorrhea?

1) An acetaminophen prescription for pain
2) An ibuprofen prescription for inflammation
3) A prescription to use a heating pad as needed
4) A complete, thorough history of the patient’s menstrual cycle and symptoms

 

 

____    4.   Which data cause the nurse to conclude that a patient is experiencing premenstrual dysphoric disorder (PMDD)?

1) Acne
2) Insomnia
3) Irritability
4) Dysmenorrhea

 

 

____    5.   Which intervention should the nurse include in the plan of care for a patient who is diagnosed with PMS?

1) Light therapy
2) Increased intake of sugary foods
3) Hormone therapy, such as prescribed drospirenone and estrogen
4) Moderate physical activity for 2.5 hours each week

 

 

____    6.   Which data collected during the assessment process cause the nurse to anticipate a diagnosis of endometriosis?

1) Fatigue
2) Light menses
3) Low back pain during cycles
4) Abdominal bloating between cycles

 

 

____    7.   A couple is interested in using a barrier method of contraception. Which statement should the nurse include in the teaching session regarding this method of contraception?

1) “An implant is inserted into the woman’s arm and releases hormones to stop ovulation.”
2) “Coitus interruptus is a barrier method in which the male does not ejaculate into the female.”
3) “Depot medroxyprogesterone acetate is administered every 3 months to the male partner.”
4) “The cervical cap is a type of barrier method that uses a clear, plastic, thimble-shaped device.”

 

 

____    8.   Which statement should the nurse include in the teaching session for depot medroxyprogesterone acetate, a hormonal contraceptive?

1) “This medication is taken daily at the same time.”
2) “This medication is administered by a patch every week.”
3) “This medication is administered by injection every 3 months.”
4) “This medication is inserted into the vagina and is used with a cervical cap.”

 

 

____    9.   Which topic should the nurse include in a discussion with a couple regarding permanent contraception options?

1) Cervical cap
2) Tubal ligation
3) Intrauterine device (IUD)
4) Depot medroxyprogesterone acetate

 

 

____  10.   Which data collected during a patient’s health history support the current diagnosis of infertility?

1) Current age of 30 years
2) Denies use of tobacco products
3) Gallbladder removal 10 years ago
4) Previous diagnosis of anorexia nervosa

 

 

____  11.   Which clinical manifestation should the nurse educate a perimenopausal woman to anticipate?

1) Night sweats
2) Cool, moist skin
3) Vaginal hypertrophy
4) Osteogenesis imperfecta

 

 

____  12.   Which treatment option should the nurse include in the plan of care for a woman who is experiencing severe vasomotor symptoms with menopause?

1) Biphosphate therapy
2) Calcium supplements
3) Vitamin D 1000 units daily
4) Low-dose estradiol 0.05-mg patch

 

 

____  13.   For which clinical manifestation should the nurse monitor when providing care to a patient who has been diagnosed with uterine fibroids?

1) Amenorrhea
2) Night sweats
3) Mood swings
4) Pelvic pressure

 

 

____  14.   Which data collected by the nurse during the health history support the suspected diagnosis of an ovarian cyst?

1) Insomnia
2) Pelvic pressure
3) Vasomotor episodes
4) Pain during intercourse

 

 

____  15.   A female patient is diagnosed with genital herpes. Which pharmacological treatment should the nurse include in the teaching session with this patient?

1) Metronidazole
2) Azithromycin
3) Ceftriaxone
4) Valcyclovir

 

 

____  16.   Which pharmacological intervention should the nurse include in the plan of care for a patient who is diagnosed with vulvovaginal candidiasis?

1) Fluconazole
2) Metronidazole
3) Triamcinolone ointment
4) Topical vaginal estrogen

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which nursing interventions should be included in the plan of care for a patient who is diagnosed with a pelvic floor disorder? (Select all that apply.)

1) Teaching Kegel exercises
2) Encouraging a low-sugar diet
3) Teaching relaxation exercises
4) Encouraging an increase in water intake
5) Providing educational materials for inserting a pessary

 

 

____  18.   Which interventions should the nurse include in the plan of care for a patient who is experiencing menopause? (Select all that apply.)

1) Encouraging weight-bearing exercise
2) Educating about the use of a transdermal estradiol patch
3) Encouraging natural approaches to coping with vasomotor episodes
4) Providing information related to the use of clonidine to treat osteoporosis
5) Providing information related to the use of selective serotonin reuptake inhibitors for hot flashes

 

 

____  19.   Which preventive health screenings should the nurse include in the plan of care for a woman who is 30 years of age? (Select all that apply.)

1) Pap test
2) Colonoscopy
3) Mammogram
4) Breast self-examination
5) Blood pressure screening

 

 

____  20.   Which clinical manifestations support the diagnosis of PMS and PMDD? (Select all that apply.)

1) Irritability
2) Dysmenorrhea
3) Monthly weight gain
4) Acne with menstruation
5) A marked lack of energy

 

 

 

Bonus Chapter 4: Adapting to Chronic Illness and Supporting the Family Unit

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is providing care to several pediatric clients in the hospital setting. Which diagnosis is capable of producing chronic limitations for the child?

1) Congenital heart defect
2) Respiratory syncytial virus
3) Pneumonia from the bacillus Haemophilus influenzae
4) Streptococcus pneumoniae, a gram-positive diplococcus

 

 

____    2.   The nurse is planning care for a school-aged child who requires oxygen, enteral tube feedings, and IV medications during the school day. In which category does this child’s chronic illness belong?

1) Handicap
2) Normalization
3) Chronic sorrow
4) Technology dependent

 

 

____    3.   Which nursing intervention is most appropriate when providing care to a child who has been diagnosed with a chronic respiratory disease and is experiencing dyspnea?

1) Administering prescribed diphenhydramine
2) Decreasing the flow of prescribed oxygen
3) Implementing guided imagery with the child
4) Repositioning the child to a low-Fowler position

 

 

____    4.   For which should the nurse monitor in an adolescent patient after the death of a close family member?

1) Delinquency
2) Spiritual distress
3) Increase in nightmares
4) Psychosomatic complaints

 

 

____    5.   The nurse is working with the parents of a child with a chronic condition. Which statement made by the child’s parents indicates the need for intervention related to an overwhelming caregiver burden?

1) “My mother moved in and helps us with the care of our family.”
2) “I have to care for my child day and night, which leaves little time for me.”
3) “I chose to quit my job to be home with my child, and my husband helps in the evening when he can.”
4) “Our health insurer sent us a rejection letter for my child’s brand-name medication, and we must fill out forms to get the generic.”

 

 

____    6.   The nurse is conducting an assessment of a parent and child with severe cerebral palsy (CP) during a routine clinic visit. Which nursing action is appropriate on the basis of the current data?

1) Measuring the urine output
2) Observing the parent-child relationship
3) Measuring the child’s head circumference
4) Observing how the child interacts during play

 

 

____    7.   The nurse is conducting an educational program for parents of children with chronic conditions. Which parental statement indicates the need for further instruction?

1) “I know my child may need specialized education.”
2) “I know my child will have to stay on a special diet.”
3) “I know my child will need assistance with activities of daily living.”
4) “I know my child will get better and not have to take any more medication.”

 

 

____    8.   An adolescent diagnosed with type 1 diabetes mellitus (DM) is prescribed dietary restrictions and daily insulin injections. Which behavior does the nurse anticipate from the adolescent upon return to school?

1) Teaching peers about the diagnosis
2) Administering medication in front of peers
3) Acknowledging the condition to classmates
4) Exhibiting poor adherence to the prescribed treatment plan

 

 

____    9.   The nurse is providing care to a toddler newly diagnosed with a chronic condition. Which nursing action will prepare the family for providing care to the toddler once he or she is discharged from the hospital setting?

1) Providing a routine for medication administration
2) Suggesting that the parents use a mobile to provide sensory stimulation
3) Allowing the child to choose the color of the gown during hospitalization
4) Suggesting the child be enrolled in a special camp to learn about the diagnosis

 

 

____  10.   The nurse works in a clinic for medically fragile children who require home care. The nurse has noticed that there is a high percentage of divorce among these families. In an attempt to reduce the divorce rate among the parents, the nurse creates an educational session for parents of medically fragile children. Which should be the focus of this session?

1) Communication
2) Financial stability
3) Ways to meet the child’s physical needs
4) State laws that have relevance to the medically fragile child

 

 

____  11.   Which nursing action is appropriate when preparing the family of a school-aged child with a chronic illness for the provision of care in the home setting?

1) Preparing the family for the transition of care into adulthood
2) Teaching the family about appropriate sensory stimuli, such as a mobile
3) Encouraging interaction between the child and others with the same diagnosis
4) Educating the family to give the child choices, such as which food to eat first

 

 

____  12.   Which term should the nurse use when talking with other members of the health-care team about a child who has a small head?

1) Acephalic
2) Procephalic
3) Hypercephalic
4) Brachycephalic

 

 

____  13.   The nurse learns that a newborn has been diagnosed with phenylketonuria (PKU). Which is the most appropriate way to inform the newborn’s parents about this diagnosis?

1) Calling the parents to provide the diagnosis over the phone
2) Planning a group meeting for all parents whose children have received the diagnosis in the last 2 months
3) Scheduling an appointment for the parents to see the health-care provider in person to discuss the diagnosis
4) Mailing a certified letter explaining the diagnosis and requesting the parents make a pediatric office appointment

 

 

____  14.   Which nursing action is appropriate for the child who is experiencing anxiety related to numerous hospitalizations required for the management of a chronic disease process?

1) Collaborating with a child life specialist
2) Spacing out procedures to allow rest in between
3) Administering antinausea medication around the clock
4) Using the Wong-Baker FACES scale for assessment purposes

 

 

____  15.   Which nursing action is appropriate for the child who is experiencing discomfort as a result of an exacerbation of a chronic disease process?

1) Collaborating with a child life specialist
2) Spacing out procedures to allow rest in between
3) Administering antinausea medication around the clock
4) Using the Wong-Baker FACES scale for assessment purposes

 

 

____  16.   Which nursing action is appropriate for the child who is experiencing fatigue as a result of an exacerbation of a chronic disease process?

1) Collaborating with a child life specialist
2) Spacing out procedures to allow rest in between
3) Administering antinausea medication around the clock
4) Using the Wong-Baker FACES scale for assessment purposes

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   The nurse is planning care for the family of a child with a chronic illness. Which activities should the nurse recommend to decrease the risk for compassion fatigue? (Select all that apply.)

1) Exercising
2) Moving away
3) Developing a hobby
4) Fostering social relationships
5) Sleeping more than 10 hours per 24-hour period

 

 

____  18.   Which human symptoms associated with the diagnosis of a chronic disease during childhood should the nurse assess for when providing care? (Select all that apply.)

1) Pain
2) Fatigue
3) Dyspnea
4) Clotting disorders
5) Vomiting and nausea

 

 

____  19.   Which teaching points should the nurse include when educating a family about the benefits of membership in the Nemours Foundation? (Select all that apply.)

1) It provides a fact sheet on asthma and children.
2) It provides information on the care of seriously ill children.
3) It provides information and ideas on balancing academics and serious illness.
4) It provides information on dealing with health conditions during adolescence.
5) It provides information on supporting siblings of children with chronic illnesses.

 

 

____  20.   Which pediatric diagnoses require the nurse to provide education related to the cardiovascular system? (Select all that apply.)

1) Head trauma
2) CP
3) Seizure disorder
4) Congestive heart failure
5) Pulmonary hypertension

 

 

 

Bonus Chapter 5: Legal Aspects of Pediatric Nursing Care

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   While making rounds, the nurse enters a room and finds an infant patient’s father violently shaking the infant. The father makes it appear as though the infant was choking. Upon further assessment, the nurse notes bruised areas on the infant’s arms and legs. What priority action should the nurse take?

1) Discussing what she witnessed with the infant’s mother
2) Discussing what she witnessed with the other nurses
3) Reporting what she witnessed and assessed to child protective services
4) Reporting what she witnessed and assessed to the local law enforcement agency

 

 

____    2.   The nurse is providing care to a child who has suffered abuse. Which nursing action is appropriate?

1) Asking the child what he did to cause his parents to beat him so badly
2) Telling the child that the individual who hurt him is a bad person
3) Following protocols for mandatory reporting
4) Asking the child what really happened

 

 

____    3.   Which criterion should the nurse review to determine if an adolescent is considered legally emancipated?

1) Over the age of 18 years
2) Resides outside of the family home
3) Legally married
4) Receives money from parents each month

 

 

____    4.   Who can provide informed consent for a school-aged pediatric patient?

1) Parent
2) Sibling
3) Physician
4) Grandparent

 

 

____    5.   The nurse receives a notice that the state board of nursing has become a member of the Nurse Licensure Compact. How does this change in the structure of the state board of nursing influence his ability to practice nursing?

1) The nurse can practice nursing only in the residing state.
2) The nurse can practice nursing in other states not listed in the compact.
3) The nurse is accountable to the state in which he and his patients reside.
4) The nurse has to obtain an additional license.

 

 

____    6.   A child on a medical-surgical unit experienced a code blue situation unexpectedly. The emergency situation has ended, and the child survived. The nurses are breaking for lunch and plan to process their feelings about the emergency. Which action by the nurses will facilitate this?

1) Discussing the event outside the hospital
2) Asking management for the use of a private room to debrief
3) Talking while riding in the staff elevator
4) Debriefing the situation at home

 

 

____    7.   The nurse is caring for a child on a medical-surgical unit that has just implemented electronic medical records for patient documentation. The child’s parent asks the nurse about the facility’s computerized system for keeping patient information, especially in regard to confidentiality. Which is the best response by the nurse?

1) “I can see why you’re worried, with all the computer hackers out there these days.”
2) “Our system was designed with a lot of input from nursing staff.”
3) “Information in the electronic medical record requires a password to retrieve.”
4) “Don’t worry; your child’s information is always safe.”

 

 

____    8.   A home health-care case manager often receives documents pertaining to the care of patients through a shared fax machine. The case manager is aware of how important it is to protect each patient’s health information. Which action by the nurse ensures that the HIPAA requirements are met in this situation?

1) Having transmitting agencies call before any information is sent
2) Taking relevant information over the phone
3) Having the patient sign a consent form for information to be released
4) Not utilizing the fax machine; depending on the mail system

 

 

____    9.   Which term should the nurse use to describe a wrongful act that produced harm, regardless of whether or not the act was committed intentionally or unintentionally?

1) Tort
2) Crime
3) Negligence
4) Malpractice

 

 

____  10.   Which entity may allow a peer assistance program for a nurse who is found guilty of providing patient care while impaired by drugs or alcohol?

1) The unit manager
2) The patient’s family
3) The state board of nursing
4) The president of the hospital

 

 

____  11.   During an assessment of a child in the urgent care clinic, the nurse notes that the child has a swollen and split lip. When asked how the child’s lip injury occurred, the parent responds, “We are here for my child’s ear, not my child’s lip.” Which is the rationale for reporting this incident?

1) The child reports that a parent caused the injury.
2) The lip injury is unrelated to the ear infection.
3) The nurse can be sued if there is abuse.
4) The suspected abuse must be reported.

 

 

____  12.   An adolescent patient with a sexually transmitted infection (STI) says to the nurse, “Promise you won’t tell my parents about my condition.” Which action by the nurse is appropriate?

1) Disclosing information to the parents
2) Communicating only necessary information
3) Respecting the patient’s privacy and confidentiality
4) Honoring the patient’s wishes

 

 

____  13.   A novice nurse attends a lecture regarding risk management. Which action should the nurse implement to reduce risks in practice?

1) Not discussing errors made
2) Purchasing liability insurance
3) Storing unused equipment in the halls of the unit
4) Questioning every order that the physician writes

 

 

____  14.   The nursing instructor is evaluating the success of training provided to staff nurses on ways to reduce the incidence of pediatric medication errors. Which observation indicates the need for additional training?

1) Staff nurses are double-checking medication calculations.
2) Staff nurses are using liquid preparations.
3) Staff nurses are asking the pharmacy to prepare the exact doses.
4) Staff nurses are asking each other to validate placement of decimal points.

 

 

____  15.   A medication error occurred, and the nurse is preparing to complete an incident report. Which information is extraneous and should be excluded from the report?

1) Name of the client involved in the incident
2) Location of a completed incident report in the medical record
3) Date and time of the incident
4) Medication involved in the incident

 

 

____  16.   Which is the priority when providing care for a pediatric patient who is the victim of child abuse?

1) Exploring options for self-development
2) Improving quality of life by increasing self-esteem
3) Exploring options for getting help for the parent
4) Ensuring the child is safe

 

 

____  17.   From which child should the nurse obtain assent during the informed consent process?

1) A 4-year-old patient
2) A 5-year-old patient
3) A 6-year-old patient
4) A 7-year-old patient

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  18.   A nurse working on a medical-surgical unit wants to ensure that care is provided within the standard of nursing care. Which actions by the nurse are appropriate? (Select all that apply.)

1) Analyzing the position description
2) Reviewing and becoming familiar with the policy and procedure manual
3) Questioning the value of collaborating with other disciplines
4) Ensuring that the nursing process steps are practiced
5) Adhering to national standards of practice and care

 

 

____  19.   The nurse is asked to participate on a committee to ensure that no breaches of confidentiality occur when providing care. Which actions help ensure patient confidentiality when providing care? (Select all that apply.)

1) Withholding private information from other staff unless needed for care
2) Sharing the name and diagnosis of clients upon request
3) Discussing patient care with nurses on other units
4) Restricting the discussion of patient care to the report room
5) Reviewing the patient’s care needs with a designated health insurance agent

 

 

____  20.   The nurse is concerned about being sued for negligence when providing care. Which nursing actions may be grounds for negligence? (Select all that apply.)

1) Patient fell getting out of bed because the call light was not used.
2) Patient’s name band was checked prior to providing all medications.
3) Patient’s morning medications were administered in the early afternoon.
4) Patient states misunderstanding activity restrictions, and a wound is eviscerated.
5) Patient documentation did not include the appearance of an infiltrated IV site.

 

 

 

Bonus Chapter 6: Providing a Safe Environment: Home and School

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A parent is concerned about her 8-year-old child’s recent behavior and calls the nurse for advice. According to the parent, her child is constantly crying, is not sleeping well, has withdrawn from activities, and does not want to attend school. Which should the nurse explore in more detail with the parent?

1) Bullying
2) Sexual abuse
3) Lead poisoning
4) Drug abuse

 

 

____    2.   Which child is at greatest risk for drowning if left alone in the tub?

1) Infant
2) Toddler
3) Preschooler
4) School-aged child

 

 

____    3.   The nurse is conducting a home risk assessment for a family with a toddler and preschool-aged children. Which finding is considered a safety hazard for this family?

1) Safety plugs in electrical outlets
2) Medications on the kitchen counter
3) Lack of helmets next to the bicycles
4) Deadbolt locks on the doors

 

 

____    4.   The nurse is conducting a home safety class for a group of parents in the community. Which lesson should the nurse teach families to maintain safety in the home?

1) Recycle containers by removing the labels and refilling them.
2) Use overloaded outlets only when necessary.
3) Keep plants in the home.
4) Always pull a plug at the plug-in from the wall outlet.

 

 

____    5.   The home health nurse is talking with a parent outside the bathroom door while the toddlers are playing in the tub. Which parental statement requires further safety teaching?

1) “Why don’t we talk in the living room?”
2) “Let me get the children out of the tub so we can talk.”
3) “I do not like to leave the children alone in the bathroom.”
4) “I often bathe the children together.”

 

 

____    6.   The nursing instructor is educating a group of nursing students about sports-related injuries. Which comment by a student nurse indicates the need for further instruction?

1) “Patients who participate in sports, strenuous exercise, or athletics of any kind should be educated about the dangers of unreported head injuries.”
2) “Adolescents are at greatest risk for not reporting sports-related injuries.”
3) “Young adults are at greatest risk for not reporting sports-related injuries.”
4) “Patients who have been injured playing a sport need to be counseled on the risks of unreported concussions.”

 

 

____    7.   While giving the history of their 10-year-old child, the parents admit to owning firearms. On the basis of this information, which should the nurse suggest to enhance the child’s safety?

1) Putting away all the guns and keeping them out of the child’s reach
2) Taking the child to a shooting range for lessons on how to use a gun properly
3) Storing the guns and ammunition in the same place
4) Using a gun lock on all firearms in the house

 

 

____    8.   Which characteristic of abusers should the nurse include in a teaching session on child abuse for elementary school teachers?

1) History of alcoholism
2) Having many friends and families nearby
3) Having realistic expectations for the child
4) A stranger to the child

 

 

____    9.   Which should the nurse include in the discharge teaching to ensure safety for a newborn at home?

1) Keeping the baby warm on the car ride home
2) Ensuring the car seat is in the center of the backseat and is rear facing
3) Keeping the baby’s head covered
4) Placing the baby on his or her back to sleep

 

 

____  10.   Which precaution should the nurse include in a kitchen safety checklist to decrease the risk for home injury to a pediatric patient?

1) Placing pots and pans on the rear burner
2) Placing cosmetics out of the child’s reach
3) Placing emergency numbers for poison control by the phone
4) Placing dangerous items out of reach when playing hide-and-seek

 

 

____  11.   Which precaution should the nurse include in a bathroom safety checklist to decrease the risk for home injury to a pediatric patient?

1) Placing pots and pans on the rear burner
2) Placing cosmetics out of the child’s reach
3) Placing emergency numbers for poison control by the phone
4) Placing dangerous items out of reach when playing hide-and-seek

 

 

____  12.   Which information should the nurse include in the teaching plan for pediatric patients to decrease the risk for dog bites?

1) Encouraging the child to approach an unfamiliar dog
2) Allowing the child to touch a dog that is eating or drinking
3) Touching a dog that is accompanied by an owner
4) Having a dog smell the child’s hand prior to petting

 

 

____  13.   Which information should the nurse include in car seat safety instructions for the parents of a 2-year-old child?

1) The child should be placed in a forward-facing car seat.
2) The child should be placed in a rear-facing car seat.
3) The child may be able to use a booster seat.
4) The child may be able to use a seat belt.

 

 

____  14.   Which information should the nurse include in car seat safety instructions for the parents of a 5-year-old child?

1) The child should be placed in a forward-facing car seat.
2) The child should be placed in a rear-facing car seat.
3) The child may be able to use a booster seat.
4) The child may be able to use a seat belt.

 

 

____  15.   Which information should the nurse include in car seat safety instructions for the parents of an 8-year-old child?

1) The child should be placed in a forward-facing car seat.
2) The child should be placed in a rear-facing car seat.
3) The child may be able to use a booster seat.
4) The child may be able to use a seat belt.

 

 

____  16.   Which information should the nurse include when assisting the parents of a school-aged patient in choosing a safe playground?

1) Choose a wooden play structure.
2) Find a slide in direct sunlight.
3) Ensure a lack of litter in the area.
4) Measure the incline of the slide to be 45 degrees.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which information should the nurse include when teaching the parents of pediatric patients methods for decreasing sun exposure? (Select all that apply.)

1) Keep infants out of direct sunlight.
2) Play outside between 10 a.m. and 4 p.m.
3) Apply a sunscreen with an SPF of at least 15.
4) Use an SPF of at least 50 for infants younger than 6 months.
5) Wear sunglasses to decrease eye exposure to the sun.

 

 

____  18.   Which information should the nurse include in a teaching plan regarding Internet safety for an older school-aged child? (Select all that apply.)

1) Implement tracking software.
2) Use content blockers and filters.
3) Verify sites periodically to ensure content.
4) Encourage the use of Facebook to promote social ties with peers.
5) Ask the child to post on social media sites when away from home.

 

 

____  19.   Which information from the Slop! Slop! Slop! Campaign should the nurse include in a teaching plan to reduce sun exposure? (Select all that apply.)

1) Use sunglasses to protect the eyes.
2) Apply sunscreen with an SPF of 50.
3) Wear a shirt when outside.
4) Cover the head with a hat.
5) Encourage outdoor activities before 10 a.m.

 

 

____  20.   Which common houseplants may pose a danger to a child if eaten? (Select all that apply.)

1) Lilies
2) Roses
3) Mums
4) Azaleas
5) Poinsettias

 

 

 

Bonus Chapter 7: Families Experiencing Stressors

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which adolescent behavior reported by a parent should cause the nurse to suspect possible substance abuse?

1) Becoming very involved with friends and in activities related to basketball
2) Becoming moody, crying, and weeping 1 minute and then cheerful and excited the next
3) Receiving numerous detentions for sleeping in class
4) Wearing baggy, oversized clothing and dyeing the hair black

 

 

____    2.   Which finding indicates that an adolescent patient is experiencing spiritual strength?

1) Telling her family over the telephone that a diagnosis is bad
2) Reading religious-based materials
3) Wringing her hands and softy repeating, “I am not ready to die”
4) Crying while sitting in a chair alone

 

 

____    3.   Which assessment findings indicate to the nurse that an adolescent patient is experiencing stress?

1) Chewing on a fingernail
2) Checking his or her cellular phone
3) Reading a magazine
4) Talking with others

 

 

____    4.   Which intervention will help a patient who is demonstrating stress about being hospitalized and concern about the needs of the children at home?

1) Asking if anything is needed once the patient is discharged to home
2) Asking if there is anyone who can help with the family at home during recuperation
3) Finding out if the children can be sent to a grandparent’s home until the client fully recovers
4) Suggesting a transfer to a long-term care facility to ensure a full recovery

 

 

____    5.   The nurse is assessing a school-aged child who demonstrates physiological manifestations of a stress response. Which physiological manifestations result from the inhibition of the parasympathetic nervous system?

1) Dry oral mucous membranes
2) Increased heart rate
3) Increased respiratory rate
4) Hyperactive bowel sounds

 

 

____    6.   While caring for her critically ill child, a mother becomes distraught and begins to cry loudly while stroking the child’s face. Which is the best response by the nurse?

1) Explaining the procedure that will occur with the treatment
2) Telling the mother that she needs to control herself for the benefit of her child
3) Taking the mother out of the room and comforting her
4) Distracting the mother by having her straighten the linens on the bed

 

 

____    7.   Which nursing intervention minimizes the stress and anxiety of hospitalization for a pediatric patient?

1) Explaining all procedures in detail before performing them
2) Controlling the environment of healing
3) Demonstrating staff competence by using multiple nurses for care
4) Letting the patient make the majority of decisions about the plan of care

 

 

____    8.   Which is the priority nursing action when providing care to a child who demonstrates signs of escalating anxiety?

1) Isolating the child in a safe, quiet, and protective environment
2) Leaving the child alone in a room
3) Providing benzodiazepine
4) Phoning the pediatrician

 

 

____    9.   Which is an appropriate response by the nurse when providing care for an adolescent patient who is experiencing a situational crisis?

1) “I know just how you feel.”
2) “I am sorry this happened to you.”
3) “You should try to stay busy.”
4) “It could have been worse.”

 

 

____  10.   When planning interventions to address a pediatric patient and family in crisis, which action by the nurse is appropriate?

1) Developing the plan prior to meeting with the patient and family
2) Conducting a complete assessment
3) Determining follow-up
4) Focusing on long-term problems

 

 

____  11.   Which initial parental feeling should the nurse anticipate when providing care to a pediatric patient who is the victim of trauma?

1) Hopelessness
2) Fear
3) Spiritual distress
4) Anger

 

 

____  12.   A pediatric patient arrives by life flight to the hospital after experiencing multiple traumas in a motor vehicle crash involving a suspected drunk driver. Which statement is most important for the nurse to make to the parents before they see their child?

1) “You should press charges against the drunk driver.”
2) “Your child’s condition is very critical; her face is swollen, and she might not look like herself.”
3) “Your child’s leg was crushed and might have to be amputated.”
4) “Don’t worry; everything will be okay. We will take excellent care of your child.”

 

 

____  13.   The nurse is speaking with a preschool-aged child whose sibling recently died. Which feelings should the nurse anticipate from the preschool-aged child?

1) The child may feel that his or her bad behavior caused the sibling’s death as a punishment.
2) The child may feel that the sibling died as a result of a fight.
3) The child may feel that having bad thoughts about the sibling caused the death.
4) The child may feel that the sibling died because the parents did not like that sibling.

 

 

____  14.   The mother of a dying 3-year-old child posts this message on Facebook: “Family and friends, Michael’s heart is giving out. Looks like it will be tonight. He is surrounded by family and not in pain. I treasure every minute of being his mother. Pray for us.” According to Elisabeth Kubler-Ross, which stage of grieving is the mother experiencing?

1) Denial
2) Acceptance
3) Bargaining
4) Depression

 

 

____  15.   The nurse is leading a recovery group for parents who have lost a child. As the opening topic for the night’s discussion, the nurse reviews information about the grief process with the parents and talks about how different people grieve. Which parental statement indicates the need for more education regarding the grieving process?

1) “I understand that everyone grieves differently.”
2) “Looking back, I realize why I became so angry when the doctors didn’t cure my daughter.”
3) “It’s been 6 months since my son died, so why isn’t my wife ready to move on with our lives?”
4) “I’m glad you described some common grief reactions. I thought I was going crazy for a while.”

 

 

____  16.   The nurse is working with the parents of a child with a chronic condition. Which statement made by the child’s parents indicates the need for intervention related to overwhelming caregiver burden?

1) “My mother moved in and is helping us with the care of our family.”
2) “I chose to quit my job to be home with my child, and my husband helps in the evening when he can.”
3) “I have to care for my child day and night, which leaves little time for me.”
4) “Our health insurer sent us a rejection letter for my child’s brand-name medication, and we must fill out forms to get the generic.”

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   The nurse is caring for a client in crisis. While providing care, the nurse must communicate effectively with this client. Which statements about communicating with clients in crisis are true? (Select all that apply.)

1) Communication should be frequent.
2) Communication should be brief.
3) Communication should be simple.
4) Communication should be detailed.
5) Communication should be directive.

 

 

____  18.   The nurse is providing care to a child who was admitted to the pediatric intensive care unit (PICU) after a motor vehicle crash. Which interventions should the nurse include in the plan of care to allow the parents to participate in their child’s care? (Select all that apply.)

1) Encouraging the parents to brush the child’s hair
2) Teaching the parents how to perform range-of-motion exercises with their child
3) Allowing the parents to read to their child
4) Explaining the child’s condition to the parents
5) Providing permission for the parents to remain at the child’s bedside

 

 

____  19.   Which defense mechanisms should the nurse include in the parental teaching session regarding common pediatric responses to a life-threatening illness? (Select all that apply.)

1) Regression
2) Anticipating
3) Denial
4) Repression
5) Bargaining

 

 

____  20.   Which nursing actions are appropriate when responding to a pediatric patient’s family member who threatens harm or violence? (Select all that apply.)

1) Attempting to talk the family member down
2) Engaging the assistance of a security guard
3) Knowing institutional codes
4) Notifying local law enforcement
5) Blocking the exit

 

 

 

Chapter 1: Healthy People 2020 and Initiatives for Healthy Families

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which statement is accurate regarding the Healthy People 2020 initiative related to families, children, and infants?

1) Most of the Healthy People documents apply specifically to infants and children.
2) Healthy People documents address the good health of adults, which benefits children.
3) There are no Healthy People initiatives specifically addressing infants or children.
4) The only initiative impacting families, infants, and children encourages breastfeeding.

 

 

____    2.   What two federal agencies oversee objectives related to maternal, infant, and child health in the Healthy People 2020 initiative?

1) The Department of Agriculture and the Centers for Disease Control and Prevention
2) The Department of Children and Youth Services and the Health Resources and Services Administration
3) The Centers for Medicare & Medicaid Services and the Health Resources and Services Administration
4) The Centers for Disease Control and Prevention and the Health Resources and Services Administration

 

 

____    3.   Who created the original Healthy People initiative?

1) The Centers for Disease Control and Prevention
2) The Health Resources and Services Administration
3) President Jimmy Carter
4) The surgeon general of the United States

 

 

____    4.   Which initiative did not demonstrate improvement over the past decades?

1) Air quality
2) Childhood exposure to secondhand smoke
3) Suicide and depression in adolescents
4) Increased physical activity for adults

 

 

____    5.   One initiative of Healthy People 2020 is to increase the proportion of infants who are breastfed. What is the maternity nurse’s primary role in helping to meet this initiative?

1) All nurses should become lactation consultants.
2) Increasing the percentage of employers that offer a place to pump breast milk
3) Providing support and teaching immediately after birth
4) Increasing the percentage of live births in hospitals

 

 

____    6.   How can maternal and pediatric nurses promote Healthy People objectives for their clients?

1) Provide all patients with a copy of the current Healthy People objectives
2) Plan care that includes teaching and support for Healthy People objectives
3) Require all new mothers to breastfeed while hospitalized
4) Discourage the father from ever bottle feeding the newborn

 

 

____    7.   When the Healthy People 2020 initiatives are reviewed, which initiative related to infants and young children has shown improvement?

1) Suicide rates in adolescents
2) Increased life expectancy
3) Babies put to bed on their backs
4) Infant mortality rates

 

 

 

Chapter 2: Introduction to Maternity Nursing

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   What impact did moving births to hospitals in the early 20th century have on the rate of complications and deaths?

1) Dramatic decline
2) Slow decline
3) Slight increase
4) Drastic increase

 

 

____    2.   What was the motivating factor for advancing nursing roles in the care of women in the early 20th century?

1) Lack of access to health care for poor women and those in rural areas
2) Patients’ modesty and desire to be cared for by a woman
3) Fear of death if attended by a physician
4) Changes in laws and regulations

 

 

____    3.   Which statement most accurately describes how maternity nursing has changed over the last 50 years?

1) Nurses have assumed many duties once assigned to physicians.
2) Nurses no longer assist physicians in caring for the laboring patient.
3) Nurses are reducing infant mortality by taking on greater responsibilities.
4) Nurses are responsible for delivering more infants than physicians are.

 

 

____    4.   A patient is admitted to the labor and delivery unit, and a plan of care based on that patient’s needs is developed by which member of the health-care team?

1) Licensed practical nurse (LPN)/Licensed vocational nurse (LVN)
2) Registered nurse (RN)
3) Nurse practitioner
4) Certified nurse midwife

 

 

____    5.   How does a nurse practitioner’s role differ from that of a certified nurse midwife with regard to maternity care?

1) The nurse practitioner does not usually deliver babies but cares for women before and after delivery.
2) The certified nurse midwife cannot prescribe medications, but a nurse practitioner does have prescribing privileges.
3) The certified nurse midwife is hired by the hospital, whereas a nurse practitioner practices independently and does not have hospital privileges.
4) The certified nurse midwife and the nurse practitioner have very similar roles with little difference between the two.

 

 

____    6.   When moving to a new state, the nurse learns the scope of practice in the new state by doing what?

1) Reading the Nurse Practice Act on the Board of Nursing Web site
2) Asking other nurses with the same credentials what they are allowed to do
3) Following the scope of practice learned in nursing school
4) Reviewing research articles to find evidence of best practices

 

 

____    7.   Which organization establishes standards of care for maternity nursing?

1) American Nurses Association
2) American Academy of Pediatrics
3) Association of Women’s Health, Obstetric and Neonatal Nurses
4) National League for Nursing

 

 

____    8.   The nurse wants to establish an evidence-based practice. Where can evidence be found to support a change in the way a procedure is performed?

1) Past experience
2) Facility procedure manual
3) Nursing research
4) Nursing organizations

 

 

____    9.   The provider explains the need for an amniocentesis, but the patient declines the procedure. The nurse supports the patient’s right to make this decision, demonstrating an understanding of which ethical principle?

1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice

 

 

____  10.   The nurse joins a community outreach program to promote vaccination of children, demonstrating which ethical principle?

1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice

 

 

____  11.   The nurse working in an acute care facility makes it a point to never look at the declaration page showing the patient’s insurance or lack of insurance because of a belief that all patients should be treated equally. This demonstrates which ethical principle?

1) Autonomy
2) Beneficence
3) Nonmaleficence
4) Justice

 

 

____  12.   A patient asks the student nurse whether a medication is safe to take during pregnancy. The student thinks it is an approved medication during pregnancy. Which is the student’s best response?

1) “I’m pretty sure it is a safe medication.”
2) “I’m not qualified to answer that question.”
3) “I will ask your obstetric provider.”
4) “I really don’t know.”

 

 

____  13.   Which statement made by a nursing student to a patient indicates the need for the nursing instructor to clarify the student’s role in providing maternity care?

1) “I’ve had three children, and I know from experience how helpful Lamaze breathing is to pain control.”
2) “You’re not allowed to have anything to eat this close to delivery, but let me get you some ice chips.”
3) “You’re doing really great. You’re almost fully dilated, so it won’t be much longer now. Hang in there.”
4) “You said you wanted to deliver without taking pain medications. Are you sure you want to change your mind now?”

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  14.   The nurse working in the neonatal intensive care unit (NICU) sits with the family as the provider explains that the neonate has no hope of survival and recommends discontinuation of life support. Which ethical dilemma(s) should the nurse identify in this situation? (Select all that apply.)

1) Quality of life versus quantity of life
2) The cost of providing futile care
3) Euthanasia versus God’s will
4) Lack of support for decision making
5) Knowledge deficit

 

 

____  15.   The nurse working in an obstetric clinic admits a woman who is 5 months pregnant and admits to a heroin addiction. Which interventions will be effective in meeting the nurse’s ethical obligation to the unborn fetus? (Select all that apply.)

1) Reporting the patient’s heroin use to the police
2) Teaching the patient about the impacts to babies born to heroin addicts
3) Providing referrals to community resources for drug treatment
4) Discussing the option of abortion because the mother will be unable to care for the child
5) Determining whether the patient has family support during her pregnancy

 

 

 

Chapter 3: Human Reproduction and Fetal Development

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is teaching a class about female reproduction for middle school girls. Which statement made by one of the students requires the nurse to correct a misunderstanding?

1) “Boys have a penis that gets erect when they are excited, but girls don’t have anything like that.”
2) “Bartholin glands secrete a lubricant to make sexual intercourse more comfortable.”
3) “The ovaries secrete eggs that, when fertilized, start a baby growing in the woman’s body.”
4) “The fallopian tubes are the passageways for eggs to travel to the uterus.”

 

 

____    2.   A pregnant woman lives in a community that is experiencing a measles outbreak because of a lack of immunization. The woman says she heard that measles are teratogenic and does not know what that means. Which statement by the nurse best explains this concept?

1) “The growing baby can catch measles and get very sick.”
2) “The measles virus acts as a harmful substance that could hurt the fetus.”
3) “A teratogen, such as the measles virus, can cause fetal death.”
4) “It means that a mother exposed to measles will probably miscarry.”

 

 

____    3.   The nurse is caring for a young man with testicular cancer who is preparing for removal of the left testicle. The patient asks, “Does this mean I won’t be able to father a child?” Which is the nurse’s best response?

1) “You can arrange with your doctor to have sperm frozen and stored for when you want children.”
2) “Although your sperm count will be lower, there is still a chance you could father a child. However, it may take longer.”
3) “This is an important discussion to have with your physician, who can discuss the chances of fathering a child.”
4) “Removal of one testicle will have no impact on your ability to father a child because the other testicle will function.”

 

 

____    4.   An adult woman’s laboratory studies indicate a lack of estrogen production. As a result, the nurse anticipates the patient’s history will report which finding?

1) Inability to produce breast milk
2) Small breast size
3) Inability to carry a pregnancy to term
4) Inability to become pregnant

 

 

____    5.   The nurse admits a woman in the second trimester of pregnancy to the obstetric clinic for her regular examination. The patient asks the nurse if it is safe to take acetaminophen for minor pain during pregnancy. Which is the nurse’s best response?

1) “Acetaminophen is a Category A medication, so it is safe to take during pregnancy.”
2) “The safest thing for the growing fetus is to avoid all medications during pregnancy.”
3) “What kind of medication have you taken in the past for minor pain?”
4) “Talk with the provider about the safest medications to take during pregnancy.”

 

 

____    6.   The nurse caring for a family shortly after a birth overhears the father of the baby say, “Well, you gave me another daughter. I guess you can’t produce boys.” Which is the nurse’s best response?

1) “It is the father who determines the sex of the baby.”
2) “Girls are nice, too, and are often closer to their father than boys.”
3) “It isn’t the mother’s fault when girls are produced instead of boys.”
4) “There are scientific methods of producing male children if you are interested.”

 

 

____    7.   The newborn nursery nurse admits a baby born with a congenital defect of the digestive tract and recognizes this is due to an anomaly in which layer during cell differentiation?

1) Ectoderm
2) Mesoderm
3) Endoderm
4) Pyloderm

 

 

____    8.   A fetal ultrasound demonstrates a cardiac anomaly in a 22-week fetus. The mother says, “My baby is sick, all because I insisted on having a cup of coffee last week.” Which statement by the nurse is most appropriate?

1) “Caffeine is a stimulant and impacts the baby by speeding up the heartbeat and increasing activity, which can result in metabolic problems.”
2) “The fetal heart is beating and pumping blood by 4 weeks and is fully formed by 8 weeks, so your actions last week did not affect your baby’s heart.”
3) “What’s done is done and can’t be undone, but try to follow the doctor’s advice from this point onward in your pregnancy.”
4) “Drinking coffee doesn’t cause any problem for the fetus, so don’t feel bad about what you did last week.”

 

 

____    9.   A mother goes into preterm labor and delivers a baby who weighs 435 g and has fused eyelids. The nurse assesses the infant at what stage of gestational development?

1) 4 months
2) 5 months
3) 6 months
4) 7 months

 

 

____  10.   A woman delivers an infant assessed prenatally at 34 weeks’ gestation. Which nursing assessment indicates the baby’s gestation is closer to term than anticipated?

1) Fused eyelids
2) Hand grip reflex present
3) Sole creases on the heel of the foot
4) Earlobes that are firm and not easily creased

 

 

____  11.   Which statement indicates a mother understood the information about the function of the placenta taught by the nurse?

1) “My blood flows through the placenta into the baby and returns to my body to oxygenate.”
2) “My body removes wastes and provides nutrients and oxygen to the baby when our blood mixes.”
3) “The placenta grows and functions because of the production of progesterone from the ovaries.”
4) “The placenta separates my blood from the baby’s and produces hormones until delivery.”

 

 

____  12.   Which finding is normal when assessing a newborn shortly after birth?

1) The umbilical cord has two arteries and one vein.
2) The umbilical cord has one artery and one vein.
3) The umbilical cord has one artery and two veins.
4) The umbilical cord is 0.25 in. in diameter.

 

 

____  13.   The mother of a premature newborn is crying and tells the nurse the neonatologist said the baby will need surgery to close the patent ductus arteriosus. She asks what this is. Which is the best explanation?

1) It is an opening in the blood vessel that shunts blood away from the liver and needs to close after birth.
2) It is an opening in the aorta that shunts blood away from the lungs, which is normal in the fetus but needs to close after birth.
3) It is a small hole in the atria of the heart that shunts blood from the right atrium to the left atrium, reducing blood flow to the lungs.
4) It is a small hole in the atria of the heart that shunts blood from the left atrium to the right atrium, reducing blood flow to the lungs.

 

 

____  14.   A patient who recently delivered twins has learned that each baby has a different father. How does the nurse interpret this finding?

1) The twins are monozygotic.
2) The twins are dizygotic.
3) There was a mistake in testing because this is not possible.
4) The twins have different gestational ages.

 

 

____  15.   Which finding during a nursing assessment of twins supports the diagnosis of dizygotic twins?

1) Both twins are boys.
2) One twin weighs more than the other.
3) One twin is blonde, the other is brunette.
4) One twin required oxygen at birth.

 

 

____  16.   The nurse receives an order to administer a Category A medication to a pregnant patient. Which is the nurse’s best action?

1) Holding the medication until verifying the order with the obstetrician
2) Administering the medication as ordered
3) Calling the pharmacist and verifying the safety of this medication
4) Giving the medication only if essential to the woman’s well-being

 

 

____  17.   The nurse receives an order to administer a Category X medication to a woman of childbearing age who denies pregnancy. Which action will the nurse take before administering this medication?

1) Asking the woman if there is any chance of pregnancy
2) Requesting an order to perform a serum pregnancy test
3) Administering the medication
4) Requesting an order for a different medication

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  18.   The nurse reviews the chart of a man undergoing testing to determine the cause of infertility. Which hormone levels will the nurse review as a possible cause of the patient’s low sperm count? (Select all that apply.)

1) Follicle-stimulating hormone
2) Luteinizing hormone
3) Testosterone
4) Estrogen
5) Progesterone

 

 

____  19.   The nurse performs a cervical examination on a woman in labor and recognizes that the elasticity of the cervix results from which characteristics of the anatomy? (Select all that apply.)

1) High fibrous content of the supportive tissue
2) Large number of folds in the cervical lining
3) High collagenous content of the supportive tissue
4) Location of the uterosacral ligaments
5) Mucus-secreting glands

 

 

Completion

Complete each statement.

 

  1. Rank these events in the order in which they occur. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

1) Secretion of luteinizing hormone

2) Release of an egg

3) Release of progesterone by the corpus luteum

4) Fertilization of the ovum

5) Implantation into the

 

 

 

Chapter 4: Physical and Psychological Changes of Pregnancy

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   While assisting the physician with a physical examination, the nurse notes which sign or symptom as most definitive of a diagnosis of pregnancy?

1) Positive Goodell’s sign
2) Quickening felt by mother
3) Auscultation of fetal heart sounds
4) Breast enlargement and tenderness

 

 

____    2.   Which nursing assessment finding indicates the need for further testing before a diagnosis of pregnancy can be confirmed?

1) Audible fetal heart tones
2) Fetal movement felt by the nurse
3) Fetal ultrasound showing a growing fetus
4) Amenorrhea

 

 

____    3.   The nurse caring for a woman who is beginning the second trimester of pregnancy recognizes the need for further assessment when the woman reports which change in her body?

1) Constipation
2) Feels short of breath with mild exertion
3) Nasal congestion
4) A dark line appearing on the abdomen

 

 

____    4.   The nurse caring for a woman who is in the third trimester of pregnancy suspects a urinary tract infection on the basis of which reported symptom?

1) Urinary frequency
2) Urgency
3) Stress incontinence
4) Burning on urination

 

 

____    5.   A pregnant woman tells the nurse how clumsy she feels. Which teaching will the nurse provide?

1) Kegel exercises
2) Increased fluid intake
3) Avoidance of standing or sitting for prolonged periods
4) Wearing low-heeled shoes and using good body mechanics

 

 

____    6.   When talking with the nurse, a pregnant patient points out her darkened areolas, the linea nigra on her abdomen, and the brown patches on her forehead and nose and says, “I’m never going to be able to wear a bikini again.” Which is the nurse’s best response?

1) “Makeup will help you hide these after you have the baby.”
2) “Be sure to point these out to the doctor. You may need to see a dermatologist.”
3) “These changes normally go away after you have the baby.”
4) “Applying vitamin E oil or cocoa butter will reverse these discolorations.”

 

 

____    7.   The nurse reviews a pregnant patient’s laboratory values and notes a reduced red blood cell count and hemoglobin level. Which symptom reported by the patient results from these findings?

1) Insomnia
2) Pica
3) Fatigue
4) Leg pain

 

 

____    8.   After assessing the cardiovascular system of a pregnant woman, the nurse recognizes the need to report which finding to the provider?

1) Asymptomatic systolic murmur
2) Heart rate of 96 bpm
3) Blood pressure of 152/94 mm Hg
4) Nasal congestion

 

 

____    9.   Which symptom reported to the nurse by the patient needs to be brought to the attention of the health-care provider?

1) Vaginal itching
2) Leakage of fluid from the nipples
3) Increase in vaginal discharge
4) Breast tenderness and enlargement

 

 

____  10.   The nurse reviews the patient’s laboratory findings and suspects anemia when noting which result?

1) Hemoglobin 12.4 g/dL
2) Red blood cell count 4.1
3) White blood cell count 24.3
4) Hematocrit 53.5%

 

 

____  11.   Which finding does the nurse recognize as a normal result of pregnancy?

1) Reduction in red blood cell count
2) Reduced platelet count
3) Increased urine glucose level
4) Elevated hematocrit value

 

 

____  12.   The nurse reviews the patient’s laboratory values and sees the following:

 

Hemoglobin 12.2 g/dL
Hematocrit 42.8%
Serum blood urea nitrogen (BUN) 18 mg/dL
Serum creatinine 0.68 mg/dL
Alanine transaminase (ALT) 8 units/L
Aspartate aminotransferase (AST) 12 units/L
Alkaline phosphatase (ALP) 108 ImU/mL
Lactate dehydrogenase (LDH) 635 units/L

 

Which conclusion does the nurse draw on the basis of these findings?

1) The patient is anemic.
2) The patient has liver damage.
3) The patient has kidney damage.
4) The patient is dehydrated.

 

 

____  13.   During the woman’s first prenatal visit, she makes many statements about the recommendations she has received from her friends about maintaining her health and the health of the growing fetus. According to Reva Rubin, which maternal task is this woman demonstrating?

1) Seeking safe passage for herself and her fetus
2) Securing acceptance for herself as a mother and for her fetus
3) Learning to give of herself and to accept herself as a mother to the infant
4) Committing herself to the child as she progresses through pregnancy

 

 

____  14.   The nurse learns that a pregnant patient lost her mother when she was a teenager and recognizes that the absence of a mother figure will cause this patient to have difficulty with which of Reva Rubin’s four maternal tasks?

1) Seeking safe passage for herself and her fetus
2) Securing acceptance for herself as a mother and for her fetus
3) Learning to give of herself and to accept herself as a mother to the infant
4) Committing herself to the child as she progresses through pregnancy

 

 

____  15.   Upon examining a woman in the late second trimester of pregnancy, the nurse notes circular bruises around each wrist and circular bruises above the umbilicus. What should the nurse suspect?

1) Physical abuse from the father of the baby
2) Clumsiness resulting from changes in the woman’s body
3) The woman’s attempt to induce a miscarriage
4) A motor vehicle accident

 

 

____  16.   A pregnant woman is telling the nurse about her other children’s reaction to news of the pregnancy but says she is waiting to tell her toddler until she’s further along. Which is the nurse’s best response?

1) “If you’ve told the other children, you should also tell your toddler.”
2) “That’s a wise decision because toddlers have no concept of time.”
3) “It would’ve been better if you hadn’t told any of the children yet.”
4) “The younger the child, the sooner you should tell him to give him time to prepare.”

 

 

____  17.   When the nurse cares for a pregnant adolescent, which psychosocial assessment takes priority before teaching self-care?

1) Gestational age
2) Developmental level
3) Support system
4) School progression

 

 

____  18.   The emergency department nurse admits an adolescent who is complaining of abdominal pain and denies pregnancy. Assessment findings include a distended, pregnant-appearing abdomen and fetal heart tones. How does the nurse interpret these contradictory findings?

1) Denial of pregnancy until late in gestation is not uncommon in adolescence.
2) The adolescent is mentally ill and incapable of recognizing pregnancy.
3) The adolescent is developmentally delayed and does not recognize pregnancy.
4) Further testing is needed to determine the cause of the assessment findings.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   The nurses is caring for a pregnant Indian woman. Which observations does the nurse attribute to the woman’s cultural beliefs? (Select all that apply.)

1) The woman may play the sick role.
2) The woman may report eating a great deal of chicken broth.
3) The woman believes it is her husband’s responsibility to satisfy her food cravings.
4) The woman continues to carry heavy loads.
5) The woman does not believe doctors are necessary during pregnancy.

 

 

____  20.   The nurse working with a culturally diverse obstetric patient population recognizes which common cultural practices? (Select all that apply.)

1) Hispanic and Indian women tend to remain physically active.
2) Japanese women do not freely discuss problems with morning sickness.
3) Chinese and Japanese women avoid physical activity.
4) Hispanic women rely on older women in the family for advice.
5) Indian women expect others to satisfy food cravings.

 

 

 

Chapter 5: Antepartal Nursing Assessment

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse cares for a newly diagnosed pregnant woman with a history of three spontaneous abortions in the first trimester and an emergency Cesarean section because of breech presentation with her last pregnancy. Which health-care provider is most appropriate to care for this patient?

1) Family physician
2) Obstetrician-gynecologist
3) Certified nurse midwife
4) Doula

 

 

____    2.   A woman arrives at the clinic and tells the nurse she thinks she is pregnant. Which symptom, as related by the patient, does the nurse consider the best indicator of pregnancy?

1) Amenorrhea
2) Irritability
3) Positive urine human chorionic gonadotropin (hCG; home test)
4) Enlarged abdomen

 

 

____    3.   Which information should the nurse include when teaching a pregnant patient who is scheduled to have an abdominal ultrasound?

1) Pain medication will be administered before the procedure.
2) Do not eat or drink anything for 4 hours prior to the procedure.
3) The probe will be inserted through the vagina.
4) Do not empty your bladder prior to the procedure.

 

 

____    4.   Using Naegele’s rule, calculate the estimated date of delivery for a patient whose first day of the last menstrual period was October 8, 2016.

1) July 15, 2017
2) January 1, 2017
3) July 1, 2016
4) June 14, 2017

 

 

____    5.   The nurse is collecting a patient’s personal information to contribute to the client history. How should the nurse question the woman regarding physical abuse and safety in her living situation?

1) “Does your significant other ever hit you?”
2) “Are you happily married?”
3) “Tell me about your home life.”
4) “Tell me about your husband.”

 

 

____    6.   The clinical instructor observes a student nurse collecting the client history of a new prenatal patient. Which question asked by the student indicates that he or she needs further education?

1) “Do you use drugs?”
2) “Have you ever been pregnant before?”
3) “Are your parents and siblings living?”
4) “What is your current living situation?”

 

 

____    7.   A woman comes for her first prenatal visit and learns the obstetrician will perform a complete physical examination. She asks the nurse, “Why is a complete physical required?” Which is the nurse’s best response?

1) “Your general health will influence your pregnancy, so the doctor needs to do a complete examination.”
2) “If you have health problems, the doctor needs to know so you can receive the treatment you need to return to health.”
3) “This is a requirement for all newly pregnant women because the doctor wants to learn as much about you as possible.”
4) “The doctor wants to make sure that the baby is healthy and that your pregnancy will progress without complications.”

 

 

____    8.   The nurse reviews a patient’s medical record and sees the measurement of the ischial tuberosity is 8.5 cm. How does the nurse interpret this measurement?

1) The woman may be unable to carry the pregnancy to term.
2) The woman has an adequate blood supply to the fetus.
3) The woman may require a Cesarean section.
4) The woman will experience a prolonged labor.

 

 

____    9.   Which laboratory test does the nurse recognize as not part of the routine order set required for pregnant women?

1) Complete blood cell count (CBC)
2) Blood type and Rh
3) Papanicolaou (PAP) screen
4) Serum calcium level

 

 

____  10.   A pregnant woman looks over the required laboratory tests and asks the nurse why they need a rubella titer and varicella titer when she knows she has already received these immunizations as a child. Which is the nurse’s best response?

1) “We have to be sure that you actually received these vaccines.”
2) “Some people require booster shots to attain full immunity.”
3) “Maybe the doctor didn’t notice that you reported having had the vaccines.”
4) “Even when people have received the vaccine, they still need to be tested for immunity.”

 

 

____  11.   The nurse reviews a woman’s quadruple screen. Which finding indicates a higher risk for Down syndrome in the fetus?

1) Elevated alpha-fetoprotein level
2) Elevated hCG level
3) Elevated unconjugated estriol level
4) Low level of inhibin A

 

 

____  12.   Which potential complication is the nurse unlikely to associate with amniocentesis?

1) Spontaneous abortion
2) Leaking of amniotic fluid
3) Infection
4) Maternal liver damage

 

 

____  13.   At which point will the nurse begin scheduling a pregnant woman for weekly obstetric visits?

1) 22 weeks
2) 28 weeks
3) 36 weeks
4) 38 weeks

 

 

____  14.   A patient is late for her prenatal visit, and when she arrives she blames symptoms, suggesting a urinary tract infection for her late arrival. Upon examination, the nurse finds mild spotting and notes bruising on the woman’s abdomen. What does the nurse suspect?

1) Preterm labor
2) Placental abruption
3) Pre-eclampsia
4) Domestic abuse

 

 

____  15.   The nurse caring for a woman at 32 weeks’ gestation finds elevated protein and nitrate levels in the urine. What will the nurse assess for next?

1) Symptoms of pre-eclampsia
2) Symptoms of a urinary tract infection
3) Symptoms of gestational diabetes
4) Inadequate nutrition

 

 

____  16.   The nurse admits a patient who arrives late for her appointment. The examination demonstrates vaginal spotting, anxiety and depression, reports of alcohol abuse, and bruising on the chest and abdomen. Which question is most appropriate for the nurse to ask?

1) “Do you have reliable transportation?”
2) “Have you considered giving the baby up for adoption?”
3) “Are you experiencing any rhythmic abdominal pain?”
4) “Has your partner ever hit you during a fight?”

 

 

____  17.   The nurse is unable to locate fetal heart tones in a woman who is at 10 weeks’ gestation. What is the nurse’s priority action?

1) Reassuring the woman that this is a normal finding
2) Notifying the provider immediately
3) Recommending complete bedrest
4) Scheduling the patient for an abdominal ultrasound

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  18.   The nurse reviews a pregnant patient’s medical record and sees G5, T2, P5, A1, L5. Which statements reflect an accurate analysis of this information? (Select all that apply.)

1) The woman has been pregnant a total of five times, including the current pregnancy.
2) The woman requested to have one pregnancy terminated.
3) Two of the children born alive died after birth.
4) One pregnancy resulted in the birth of quintuplets.
5) The woman adopted one of her children.

 

 

____  19.   The nurse is examining a woman who is at 20 weeks’ gestation. Which findings does the nurse consider appropriate at this stage of pregnancy? (Select all that apply.)

1) Fundal height – 20 cm
2) Fetal heart rate – 148 bpm
3) Quickening
4) +1 glycosuria
5) 3-lb weight loss

 

 

Completion

Complete each statement.

 

  1. The nurse is caring for a woman who is 16 weeks pregnant. One child was born at term, and a set of triplets were born at 26 weeks’ gestation (one of whom died at 3 years of age). She experienced two spontaneous abortions prior to 8 weeks of pregnancy and had one therapeutic abortion many years ago as a young teen. Document the GTPAL for this patient by filling in the appropriate number for each letter.

 

G___T___P___A___L__

 

 

 

Chapter 6: Nursing Care During Pregnancy

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is caring for a pregnant woman who is complaining of nasal stuffiness. Which intervention does the nurse identify as problematic and encourage the patient to stop?

1) Increased fluid intake
2) Use of nasal saline drops
3) Use of a humidifier in the home
4) Taking a decongestant

 

 

____    2.   Which statement made by a pregnant woman who is complaining of increased vaginal discharge should the nurse correct?

1) “I try to wear loose clothes and avoid anything that too tight fitting.”
2) “I changed from my usual nylon underwear to cotton underwear.”
3) “The discharge has gotten so bad that I have to wear panty liners all the time.”
4) “I’ve started douching at least once a day and sometimes twice a day.”

 

 

____    3.   The nurse is providing teaching to a woman during her first prenatal visit. The woman says she has been told to avoid baths and asks if that is true. Which statement made by the nurse is incorrect?

1) “Baths are safe until the membranes rupture.”
2) “Apply antiskid devices to the bottom of the tub to prevent injury.”
3) “Soaking in a hot tub can be very relaxing and can reduce morning sickness.”
4) “In the third trimester, get help getting out of the bathtub.”

 

 

____    4.   When the nurse assesses a pregnant woman, which form of exercise previously enjoyed by the woman should be discouraged?

1) Running
2) Skiing
3) Swimming
4) Cycling

 

 

____    5.   The nurse teaches a pregnant woman about healthy nutrition to prevent neural tube defects in the fetus. The nurse assesses that the patient understood the teaching when which food choices are made for breakfast?

1) Bacon, eggs, and hash browns
2) Pancakes with syrup and sausage
3) Peanut butter on toast and orange juice
4) Cereal with milk and peanut butter on toast

 

 

____    6.   Which question from the nurse is most effective in assessing a pregnant patient for potential pica?

1) “You’re not eating anything that would be considered a nonfood item, are you?”
2) “Are you eating anything weird that you didn’t eat before you got pregnant?”
3) “Some women experience cravings. Are you experiencing anything like that?”
4) “Pica, a craving to eat nonfood items, is common in pregnancy. What have you experienced?”

 

 

____    7.   During a woman’s routine prenatal visit, the nurse notices scratches on her arms and learns she has adopted a kitten. Which teaching should the nurse include during this visit?

1) Cytomegalovirus prevention
2) Toxoplasmosis prevention
3) Rubella prevention
4) Parvovirus prevention

 

 

____    8.   During the prenatal visit of a woman who is 38 weeks pregnant, the pelvic examination reveals active genital herpes. Which anticipatory guidance should the nurse provide?

1) Potential for the newborn to require neonatal intensive care
2) Increased risk of congenital anomaly in the neonate
3) Preparation for Cesarean section
4) Need to notify the public health department

 

 

____    9.   The nurse includes which teaching as the greatest priority when caring for a pregnant woman over age 35?

1) Healthy nutrition
2) Proper self-care
3) Regular prenatal care
4) Chromosomal testing

 

 

____  10.   The nurse is caring for a woman in the first trimester of pregnancy whose body mass index (BMI) is 16.5. Which nutritional counseling should the nurse provide?

1) Follow a healthy diet low in calories and fat.
2) Follow a healthy diet low in sodium and calories.
3) Follow a healthy diet high in protein and fat.
4) Follow a healthy diet with increased calories and calcium.

 

 

____  11.   A pregnant adolescent tells the nurse, “There is something wrong with me. I can’t sit through a class without having to urinate.” A physical examination reveals no urinary or renal problems. What is the nurse’s priority of care?

1) Telling the patient to reduce fluid intake during the school day
2) Having the patient attend a pregnant adolescent group class
3) Encouraging the patient’s mother to monitor her urine output
4) Telling the patient to have friends take notes in class while she urinates

 

 

____  12.   A pregnant adolescent asks the nurse, “Did I hurt the baby because I went to a party last night and had a few beers?” Which is the nurse’s best response?

1) “Drinking alcohol can be very harmful to the fetus, but you won’t know if harm was done until the baby is born.”
2) “Alcohol is a drug, and all drugs have the potential to harm the baby, so they should be avoided throughout pregnancy.”
3) “It is unlikely that drinking one time hurt the baby, but repeated intake of alcohol can have serious negative effects.”
4) “Drinking alcohol at your age is illegal, and I am required to report this to the authorities because I’m a nurse.”

 

 

____  13.   The nurse is teaching a pregnant adolescent about maintaining a healthy diet. Which statement by the patient indicates further teaching is needed?

1) “I’ll drink only diet soda until after I have the baby.”
2) “I will increase my calcium intake by eating more yogurt.”
3) “I will order a salad when I go to a fast-food place with my friends.”
4) “I will take a calcium supplement every day until I deliver.”

 

 

____  14.   While reviewing a new patient’s medical record prior to her arrival at the clinic, the nurse sees the patient is classified as an AMA and interprets this to mean what?

1) Advanced medical age
2) Against medical advice
3) Always making assumptions
4) Acute myeloid leukemia

 

 

____  15.   The triage nurse receives a call from a woman who is 32 weeks pregnant and reports feeling no fetal movements in the last hour. What should the nurse advise?

1) See the doctor immediately for an ultrasound examination.
2) Eat and rest, then do another kick count for 1 hour.
3) Go to the emergency department immediately.
4) Get some sleep and try again tomorrow.

 

 

____  16.   The nurse reviews a patient’s L/S ratio and sees the results are 4:1. How is this finding interpreted?

1) Mature fetal lungs
2) Immature fetal lungs
3) Inconclusive
4) Fetal demise

 

 

____  17.   Which statement by a laboring patient informs the nurse that the couple is using the Bradley method?

1) “No matter how severe the pain becomes, I do not want to take anything to control it.”
2) “I have learned all of the breathing exercises to help me control pain.”
3) “I have been practicing my relaxation techniques to help me manage the pain.”
4) “If the pain becomes more than I can handle, I will let you know and will request medication.”

 

 

____  18.   Which request does the nurse not expect to find in a birth plan?

1) Preference to avoid induction
2) Preference for an epidural to manage pain
3) Preference to deliver in a birthing chair
4) Preference for a specific drug for induction

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   The nurse is caring for a woman who had a pre-pregnancy BMI of 22.3 and has gained 53 lb. Which assessments are most important for this patient? (Select all that apply.)

1) Serum glucose
2) Blood pressure
3) Urine glucose
4) Premature rupture of membranes
5) Fetal anomalies

 

 

____  20.   The nurse provides nutritional counseling for a pregnant woman diagnosed with anemia. The woman demonstrates understanding of the dietary changes needed when choosing to increase which foods in her diet? (Select all that apply.)

1) Chicken
2) Spinach
3) Dried apricots
4) Tofu
5) Milk

 

Chapter 7: Nursing Care of the Woman With Complications During Pregnancy

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse provides teaching for a patient with hyperemesis gravidarum and determines further teaching is needed when the patient makes which statement?

1) “I will sip water throughout the day.”
2) “I will call the provider if there is any blood in the vomit.”
3) “I will be sure to eat three good meals a day.”
4) “I will not eat spicy or fatty foods till I feel better.”

 

 

____    2.   The nurse teaches a patient with hyperemesis gravidarum when to notify the provider. The nurse recognizes clarification is needed when the patient says she will notify the provider for which sign?

1) Dark urine
2) Bloody vomit
3) Inability to keep food down for 24 hours
4) Frequent urination

 

 

____    3.   A pregnant woman presents to the clinic at 16 weeks’ gestation with lack of fetal movement. Ultrasonography reveals fetal demise. How does the nurse document this pregnancy?

1) Threatened abortion
2) Inevitable abortion
3) Complete abortion
4) Missed abortion

 

 

____    4.   A woman presents to the emergency department with a history of pelvic inflammatory disease after a medical abortion, with acute vaginal bleeding and abdominal pain accompanied by shoulder pain. What does the nurse suspect as the cause?

1) Threatened abortion
2) Ectopic pregnancy
3) Gestational trophoblastic disease
4) Hyperemesis gravidarum

 

 

____    5.   The nurse is caring for a patient with blood type O-negative following a spontaneous abortion. Which is the priority of care?

1) Providing emotional support
2) Administering oxytocin
3) Notifying the laboratory for a blood type and crossmatch
4) Administering RhoGAM

 

 

____    6.   When discharging a woman following a spontaneous abortion, the nurse instructs her to report which priority complication?

1) Difficulty becoming pregnant again
2) Increased risk of future fetal demise
3) Infection
4) Weakness and lethargy

 

 

____    7.   The nurse caring for a patient 1 hour post-salpingostomy recognizes which priority of care?

1) Psychosocial support
2) Administration of RhoGAM
3) Pain management
4) Fertility planning

 

 

____    8.   When planning care, the nurse recognizes which pregnant woman as being at greatest risk for gestational diabetes?

1) A Caucasian adolescent with a diabetic mother who participates on the high school swim team
2) A 28-year-old Native American whose last pregnancy ended with a stillbirth
3) An African American adolescent with a history of cystic fibrosis and hypertension
4) A 22-year-old Caucasian woman whose last baby weighed 11 lb 3 oz at birth

 

 

____    9.   A nursing assessment reveals heavy vaginal bleeding; a firm, boardlike abdomen; contractions lasting 3 minutes with less than 30 seconds between them; and uterine tenderness in a woman last assessed to be 3 cm dilated and in early labor. Which is the nurse’s priority of care?

1) Frequent vital signs and fetal heart tones
2) Notification of the health-care provider
3) Assessment and documentation of pain levels
4) Providing emotional support

 

 

____  10.   A patient is informed that her pregnancy is a complete molar pregnancy and says to the nurse, “So my baby died?” What is the nurse’s best response?

1) “Yes, I’m afraid that’s true, but you can get pregnant again.”
2) “The pregnancy resulted in the development of a placenta, but there was no baby.”
3) “This is a genetic abnormality that resulted in a nonviable fetus.”
4) “Have you ever experienced a molar pregnancy before?”

 

 

____  11.   The nurse is caring for a patient who is 18 weeks pregnant and has a complete placenta previa. Which risk factor will the nurse assess for?

1) Multiple pregnancies
2) History of premature delivery
3) Endometriosis
4) Excessive exercise

 

 

____  12.   While caring for a patient diagnosed with an ectopic pregnancy, the nurse recognizes which sign as an indication of hypovolemic shock?

1) Elevated blood pressure
2) Decreased heart rate
3) Lethargy
4) Confusion

 

 

____  13.   Which woman is at greatest risk for Rh incompatibility?

1) A mother who has O- blood type, the father has A- blood type
2) A mother who has AB- blood type, the father has O+ blood type
3) A mother who has O+ blood type, the father has B- blood type
4) A mother who has A+ blood type, the father has B+ blood type

 

 

____  14.   The nurse is caring for a pregnant woman with a positive indirect Coombs test and type O- blood. Her last pregnancy resulted in the delivery of an infant with hemolytic anemia. Which is the priority of care?

1) Administer RhoGAM
2) Monitor the woman for anemia
3) Administer immunoglobulin at 28 weeks’ gestation
4) Prepare the patient for premature delivery

 

 

____  15.   The nurse is caring for a woman carrying multiple gestations. When providing nutritional teaching, the nurse encourages which dietary changes?

1) Increased calcium and reduced fat and calories
2) Increased folic acid and calcium and reduced protein
3) Increased calories, protein, and iron
4) Increased fat and calories with reduced protein

 

 

____  16.   The labor nurse admits a patient who is known to be carrying quadruplets at 28 weeks’ gestation and is in active labor. The nursing plan of care will include all of the following except what?

1) Encouraging the woman to verbalize her fears and ask questions
2) Continuous monitoring of fetal heart rates
3) Preparing the woman for prolonged vaginal delivery times
4) Ensuring that extra nurses and physicians will attend the birth

 

 

____  17.   The nurse is caring for one patient with chronic hypertension and another patient with gestational hypertension and recognizes which as the primary difference between the two?

1) The patient with gestational hypertension does not require medication.
2) The patient with chronic hypertension needs to maintain a low-sodium diet.
3) Blood pressure in gestational hypertension returns to normal 12 weeks postpartum.
4) Chronic hypertension carries greater risk of fetal complications.

 

 

____  18.   The nurse is caring for a patient who is in the third trimester of pregnancy and has been diagnosed with severe pre-eclampsia. Which is the nurse’s priority intervention to prevent seizures?

1) Monitoring hourly urine output and protein
2) Monitoring fetal well-being
3) Checking for hyperreflexia
4) Maintaining a low-stimulation environment

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   The nurse who is caring for a pregnant woman diagnosed with gestational diabetes includes which topics in the teaching plan? (Select all that apply.)

1) Blood sugar monitoring four times a day
2) Eating six meals per day
3) Including carbohydrates with every meal
4) Maintaining blood sugar level at less than 120 mg/dL
5) Reducing daily activity

 

 

____  20.   When caring for a pregnant patient with a history of recreational cocaine use, the nurse recognizes the woman is at risk for which disorders? (Select all that apply.)

1) Placenta previa
2) Placenta abruption
3) Placenta accreta
4) Hydatidiform mole
5) Pre-eclampsia

 

Chapter 8: Process and Stages of Labor and Birth

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____    1.   Which maternal hormones are suspected of contributing to the onset of labor? (Select all that apply.)

1) Increased oxytocin levels
2) Increased prostaglandin levels
3) Reduced progesterone levels
4) Increased cortisol levels
5) Uterine stretch theory

 

 

____    2.   Which signs do the nurse observe in a woman who is in labor? (Select all that apply.)

1) Lightening
2) Cervical effacement
3) Cervical dilation
4) Burst of energy
5) Cervical softening

 

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    3.   Which cervical change does the nurse caring for a primipara expect to find during an assessment?

1) The cervix dilates first, then begins to efface.
2) Cervical dilation occurs at the same rate as cervical effacement.
3) Cervical effacement occurs slowly, before significant dilation occurs.
4) Cervical dilation begins; then effacement reaches 100% before dilation is complete.

 

 

____    4.   The triage nurse receives a call from a pregnant woman. Which statement by the pregnant woman makes the nurse suspect the woman is experiencing false labor?

1) “The pain is in my back and circles around to the front.”
2) “The pain gets more intense when I walk.”
3) “The pain is becoming more intense and more frequent.”
4) “I’ve been timing the contractions, and they are not regular.”

 

 

____    5.   The nurse reviews the medical record of a woman admitted in labor and sees she has a narrow pelvis. Which of the seven Ps of labor does this impact?

1) Passage
2) Passenger
3) Power
4) Presentation

 

 

____    6.   When reviewing a laboring patient’s medical record, the nurse sees that a longitudinal lie has been documented. How is the fetus positioned?

1) The fetus is lying parallel with the mother’s body.
2) The fetus is lying perpendicular to the mother’s body.
3) The fetus is lying at an angle to the mother’s body, between parallel and perpendicular.
4) The fetus is in the head-down position.

 

 

____    7.   After reinforcing teaching on how to determine the duration of a contraction, the nurse determines further teaching is needed when the mother makes which statement?

1) “I will time from the end of one contraction to the end of the next contraction.”
2) “As soon as the contraction stops, I will time until the next one begins.”
3) “I will write down the exact time the contraction begins and ends.”
4) “I will time from the beginning of one contraction till the beginning of the next one.”

 

 

____    8.   A student nurse is observed providing care to a woman in active labor. The instructor recognizes the need for corrective action when the student makes which statement?

1) “You’re doing great with your breathing during contractions.”
2) “Your partner could roll tennis balls over your back during contractions to reduce pain.”
3) “Only your obstetrician can tell you how far your cervix has dilated.”
4) “I will stay with you as long as I can to help you manage labor pain.”

 

 

____    9.   Which assessment finding does the nurse recognize is the result of the laboring patient’s increasing anxiety level as contractions become stronger?

1) Abnormal fetal heart rate patterns
2) Increased uterine contractility
3) Shorter second stage of labor
4) Reduced maternal heart rate

 

 

____  10.   While being admitting, a patient in labor says, “I want plenty of narcotics so I am asleep until the baby comes.” The nurse recognizes that meeting this request will cause which risk for cesarean section?

1) The patient’s inability to push and participate in delivery
2) Risk for fetal harm secondary to medications passing through the placenta
3) Elimination of the partner’s involvement in the labor and delivery process
4) Increased contractility of the uterus as a potential side effect

 

 

____  11.   Which is the priority of nursing care for a woman in the early latent phase of labor?

1) Encourage rest between contractions
2) Encourage activity such as walking
3) Perform frequent cervical checks
4) Encourage acceptance of pain medications

 

 

____  12.   After observing a laboring patient, the experienced nurse tells the student nurse that a cervical examination will likely confirm the transition phase has begun. What did the experienced nurse observe to suggest this diagnosis?

1) The woman reports that rupture of the membranes has occurred.
2) The woman keeps saying she is so glad to finally be in labor.
3) The contractions are 2 to 3 minutes apart.
4) The woman is irritable and has trouble concentrating.

 

 

____  13.   While the doctor awaits delivery of the placenta after delivery of the newborn, the nurse documents that the patient is in which state of labor?

1) Latent
2) Second
3) Transition
4) Third

 

 

____  14.   A laboring patient begins to demonstrate irritability, snapping at her labor coach and complaining of pelvic pressure. The nurse suspects cervical assessment will reveal which dilation measurement?

1) 2 to 3 cm
2) 4 to 5 cm
3) 5 to 6 cm
4) 8 to 9 cm

 

 

____  15.   The nurse expects expulsion of the head to occur following which fetal movement?

1) Restitution and external rotation
2) Extension
3) Internal rotation
4) Flexion

 

 

____  16.   After handing a wrapped newborn to the mother, the nurse sees the umbilical cord lengthening and a sudden trickle of blood at the vaginal opening and recognizes what is about to happen?

1) Hemorrhage
2) Multiple birth
3) Placental separation
4) Uterine inversion

 

 

____  17.   When assessing maternal response to labor, the nurse sees the most significant responses in which system?

1) Cardiovascular
2) Respiratory
3) Gastrointestinal
4) Reproductive

 

 

____  18.   Which finding does the nurse identify as unexpected and concerning when assessing a woman in labor during the peak of a contraction?

1) Increased blood pressure
2) Decreased pulse rate
3) Increase in depth and rate of respirations
4) White blood cell (WBC) count of 26,000/mm3

 

 

____  19.   As the fetal head moves through the birth canal, the nurse expects which assessment finding?

1) Reduction in heart rate
2) Increase in fetal oxygen pressure
3) Decrease in fetal arterial carbon dioxide pressure
4) Increase in fetal breathing movements

 

 

____  20.   A laboring patient asks the nurse if the baby is injured during the delivery process. Which response by the nurse demonstrates understanding of fetal response to labor and delivery?

1) “Circulation and perfusion stop during contractions, so it is important not to labor too long.”
2) “The baby can’t breathe, so carbon dioxide builds up in the bloodstream and the oxygen level falls.”
3) “The stress of labor does not produce any ill effects for the baby as long as the baby is healthy.”
4) “No one really knows what happens to the baby during delivery, but it is a normal process.”

 

Chapter 9: Nursing Assessment During Labor

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse reviews the charts of patients who have expressed an interest in home birth and recommends which patient as a potential candidate?

1) A woman whose 1-year-old child was born via Cesarean section
2) A primipara with a history of infertility
3) A woman desiring an epidural for pain control
4) A woman whose last child was stillborn

 

 

____    2.   A woman considering options for where to give birth asks the nurse if home birth is safe. Which is the nurse’s best response?

1) “Home birth is safe if there are no complications for the mother or infant.”
2) “Home delivery is an option you should talk with the physician about.”
3) “Delivering at home is safe as long as there’s a hospital within a 5-minute drive.”
4) “I would never consider delivering my baby at home because of the rate of poor outcomes.”

 

 

____    3.   Which statement by the nurse is most appropriate when a patient is reluctant to sign the consent for admission?

1) “Signing this form gives us permission to take care of you.”
2) “If you don’t sign this form, we cannot take care of you.”
3) “Everyone admitted to the hospital needs to sign this form.”
4) “It’s your choice whether to sign or not sign this form.”

 

 

____    4.   Upon admitting a laboring patient, the nurse collects maternal assessment for which purpose?

1) To learn about the patient’s medication usage
2) To learn about any complications during the pregnancy
3) To establish a baseline of the patient’s condition
4) To determine any cultural needs the patient may have

 

 

____    5.   The nurse assesses a fetal heart rate as 190 bpm, with minimal baseline variability and recurring variable decelerations with moderate variability. How does the nurse classify these findings?

1) Category I
2) Category II
3) Category III
4) Falling between category II and category III

 

 

____    6.   The nurse performs an assessment of fetal heart rate and determines that the findings indicate a category I on the basis of which assessment finding?

1) Marked baseline variability
2) Recurring late
3) Fetal heart rate of 110 bpm
4) Prolonged decelerations of 5 minutes

 

 

____    7.   Under which circumstance does the nurse avoid performing a cervical examination?

1) When the membranes have ruptured
2) When vaginal bleeding is noted
3) When the woman has a multiple pregnancy
4) When the woman has complained of pain on past cervical examinations

 

 

____    8.   After Leopold’s maneuver is performed, the patient asks the nurse, “Why did you do that?” Which is the nurse’s best explanation?

1) “This is a check for fetal well-being.”
2) “This tells me if there will be any complications during delivery.”
3) “I was checking to see what position the fetus is in.”
4) “I was checking to see how you are progressing.”

 

 

____    9.   While the nurse is talking to a laboring woman, her amniotic membranes rupture. Which is the nurse’s priority of care?

1) Vital signs
2) Cervical examination
3) Assessment of fluid
4) Assessment of fetal heart rate

 

 

____  10.   The nurse is assisting with the care of multiple patients in labor and recognizes the need to notify the health-care provider for which patient?

1) A primipara whose dilation has progressed from 4 to 5 cm over the past 2 hours
2) A primipara who dilated to 6 cm, and then her contractions stopped
3) A multipara who is 7 cm dilated with an intact amniotic membrane
4) A multipara who is 8 cm dilated and is becoming irritable and restless

 

 

____  11.   When planning care, the nurse determines that which patient is appropriate for intermittent fetal monitoring?

1) The woman whose pregnancy is at 38 weeks’ gestation
2) The woman receiving an epidural anesthetic
3) The woman with controlled gestational diabetes
4) The woman whose 5-year-old was born by Cesarean section

 

 

____  12.   A patient with pregnancy-induced hypertension asks the nurse to please remove the continuous fetal monitor to allow for easier movement. Which is the nurse’s best response?

1) “I cannot remove the fetal monitor without a direct order from your provider, and there is an order to keep it on.”
2) “The fetal monitor allows me to make sure the baby is okay during contractions, so we need to leave it on.”
3) “Fetal monitoring restricts movement, but you don’t want something to happen to the baby, do you?”
4) “Let me try to adjust the monitor to give you more freedom to move about in bed so you can be more comfortable.”

 

 

____  13.   The nurse is caring for an obese pregnant woman in preterm labor with intact amniotic membranes who is receiving medications to stop labor. Which type of monitoring is best for this patient?

1) Internal fetal and contraction monitoring
2) Internal fetal and external contraction monitoring
3) External fetal and internal contraction monitoring
4) External fetal and contraction monitoring

 

 

____  14.   The nurse, while assessing a fetal monitor strip for a woman in term labor, determines there is significant fetal distress when she notes which finding?

1) Fetal heart rate of 160 bpm
2) Moderate variability
3) Accelerations of 25 bpm with contractions
4) Recurrent late decelerations with minimal variability

 

 

____  15.   When analyzing a fetal monitor strip, the nurse recognizes that which decelerations are not an indication for concern and require no nursing interventions?

1) Early decelerations
2) Late decelerations
3) Variable decelerations
4) Absent decelerations

 

 

____  16.   When analyzing a fetal heart strip, the nurse notes the absence of accelerations for the past 15 minutes. Which is the nurse’s priority action?

1) Change the maternal position
2) Notify the health-care provider
3) Administer oxygen to the mother
4) Monitor for an additional 15 minutes

 

 

____  17.   A laboring patient’s amniotic membranes rupture, and a sudden variable deceleration is seen on the fetal heart monitor. Which is the nurse’s priority action before notifying the health-care provider?

1) Increase IV fluids
2) Perform amniotic infusion
3) Change the patient’s position
4) Administer oxygen

 

 

____  18.   The nurse is caring for a patient who is receiving oxytocin to promote labor and notes late decelerations on the fetal monitor. Which is the nurse’s priority of care?

1) Performing Leopold’s maneuver to wake the sleeping fetus
2) Administering tocolytics
3) Discontinuing oxytocin
4) Increasing administration of IV fluids

 

 

Completion

Complete each statement.

 

  1. The nurse is preparing to perform a vaginal cervical examination. Place the steps the nurse will perform in the proper order, from first to last. (Enter the number of each step in the proper sequence; do not use punctuation or spaces. Example: 1234)

1) Insert the index and middle finger into the vagina

2) Open the labia and observe for vaginal drainage

3) Document findings

4) Perform hand hygiene and provide privacy

5) Position the woman

6) Determine effacement, dilation, station, and presenting part

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  20.   The nurse admits a laboring patient who is progressing rapidly and says she feels the need to push. Which priority data should be assessed with this patient? (Select all that apply.)

1) Cultural needs
2) Medication history
3) Timing of contractions
4) Cervical dilation
5) Fetal well-being

 

Chapter 10: Nursing Care During Labor

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A woman in the latent phase of labor is admitted with a diagnosis of group B Streptococcus. Which order should the nurse question?

1) Begin an infusion of lactated Ringer’s IV at 125 mL/hr
2) Collect her complete blood cell (CBC) count, blood type, Rh, and urinalysis
3) Prepare for an amniotomy
4) Administer penicillin G 5 million units IV times one dose, then 2.5 million units every 4 hours

 

 

____    2.   A patient is in active labor, 6 cm dilated, 100% effaced with intact amniotic membranes. Which procedure does the nurse anticipate?

1) Amniotomy
2) Episiotomy
3) Amnioinfusion
4) Intermittent fetal monitoring

 

 

____    3.   The physician performs an amniotomy on a laboring woman. Which is the nurse’s priority of care after the procedure?

1) Pain assessment
2) Measuring fetal heart tones
3) Assessing cervical dilation
4) Encouraging intake of clear liquids

 

 

____    4.   A woman in active labor has not progressed since reaching 6 cm dilation. Which is the nurse’s priority of care?

1) Assisting with bladder emptying
2) Administering analgesics
3) Encouraging and reinforcing relaxation and breathing
4) Encouraging position changes

 

 

____    5.   During contractions, which is the nurse’s priority teaching for a woman in active labor?

1) Encouraging proper breathing and relaxation techniques
2) Encouraging position changes
3) Encouraging urination
4) Teaching about the progression of labor contractions

 

 

____    6.   A patient in the transition phase of labor is 8 cm dilated and reports feeling the need to push. Which is the nurse’s priority teaching for this patient?

1) Warning her labor coach of potential irritability during this phase
2) Assisting with pant-blow breathing
3) Instructing her to inform the nurse of feelings of nausea
4) Assisting her into a position to push effectively

 

 

____    7.   After delivery of an infant and prior to delivery of the placenta, which is the priority assessment of the mother?

1) Suturing of any tears
2) Administering oxytocin infusion
3) Examination of the umbilical cord
4) Condition of the cervix, vagina, and perineum

 

 

____    8.   Which is the nurse’s priority of care during the immediate postdelivery period?

1) Inspection of the placenta
2) Administration of naloxone
3) Assessment of the umbilical cord
4) Care of the newborn

 

 

____    9.   A newborn has a 1-minute Apgar of 3 and a 5-minute Apgar of 5. When will the next Apgar be performed by the nurse?

1) At 6 minutes of life
2) Every 15 minutes until a score of 10 is achieved
3) 4 minutes later
4) At 10 minutes of life

 

 

____  10.   The nurse accepts a newborn from the provider immediately after delivery and assesses the 1-minute Apgar as 6. How does the nurse maintain thermoregulation for this newborn?

1) Wrap the infant in warm blankets
2) Apply a hat
3) Place the infant skin-to-skin with the mother
4) Place the infant on a radiant warmer

 

 

____  11.   A father who is watching the nurse prepare an injection of vitamin K for his infant asks why the medication is necessary. Which is the nurse’s best explanation?

1) “It is a routine procedure for all infants immediately after birth.”
2) “It prevents eye infections and preserves eyesight.”
3) “Newborns can’t produce vitamin K and are at risk for bleeding.”
4) “It is given to promote blood clotting till the newborn begins eating.”

 

 

____  12.   The nurse who is teaching a class for peers to explain the physiology of pain explains that somatic pain is caused by what?

1) Decrease in blood supply to the uterus during contractions
2) Stretching of the perineum during fetal descent
3) Afferent and efferent impulses sent from fibers near the cervix
4) The early stages of labor from stretching and dilation of the cervix

 

 

____  13.   A woman in labor uses hypnosis to manage pain, which the nurse recognizes as a component of which method?

1) Dick-Read method
2) Bradley method
3) Lamaze method
4) Leboyer method

 

 

____  14.   A laboring patient has received IV fentanyl for labor pain management and requests it again after the cervical check indicates she is 10 cm dilated and ready to start pushing. Which is the nurse’s best response to the patient’s request?

1) “Try to give one or two good pushes, and then I’ll get your medication for you.”
2) “Receiving medication now is a good idea to help you control the pain of delivery.”
3) “Administering a narcotic now could be dangerous because it will suppress the baby’s breathing.”
4) “If I give you fentanyl now, you might miss the birth of your baby because you’ll be asleep.”

 

 

____  15.   The nurse is caring for a patient who received an epidural analgesic minutes ago. Which assessment finding should the nurse report to the provider immediately?

1) A slowdown in labor contractions
2) A reduction in blood pressure
3) Complaints of numbness in the legs
4) Shortness of breath, itching, and hives

 

 

____  16.   A multipara woman presents to the labor unit in active labor, dilated to 9 cm, and requesting something to manage the pain. Which anesthetic is most appropriate for this patient?

1) Epidural
2) Spinal
3) IV narcotic
4) Local

 

 

____  17.   Which patient does the nurse consider at lowest risk for urinary retention?

1) The patient who received an IV narcotic for pain management
2) The patient who received a pudendal block prior to delivery
3) The patient who received an epidural anesthetic
4) The patient who received a spinal anesthetic

 

 

____  18.   The nurse is caring for a patient in labor with a known history of drug abuse. How does the patient’s history impact the nursing plan of care?

1) Narcotics should not be administered to someone with a history of drug abuse.
2) Higher dosages of medications may be needed to manage this patient’s pain.
3) Local anesthetics are the anesthetic of choice for this patient.
4) The woman should be encouraged to use nonpharmacological pain management.

 

 

____  19.   The nurse assesses a patient immediately after she receives an epidural anesthetic to control labor pain and notes tachycardia, hypertension, and reports of dizziness and a metallic taste in her mouth. Which is the nurse’s priority intervention?

1) Administering diphenhydramine if ordered
2) Encouraging deep breathing and relaxation techniques
3) Notifying the provider immediately
4) Administering an IV fluid bolus if ordered

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  20.   Which nonpharmacological pain relief measures can the nurse provide a laboring woman to ease the pain of contractions? (Select all that apply.)

1) Ice chips
2) A cool washcloth to the forehead
3) Progressive relaxation
4) Breathing techniques
5) Diversion and distraction

 

Chapter 11: Nursing Care of the Woman With Complications During Labor and Birth

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse admits a patient at 32 weeks’ gestation with a history of cervical cerclage to rule out preterm labor. Which finding is inconsistent with the patient’s history?

1) Rupture of membranes
2) Signs of infection
3) Cervical dilation to 3 cm
4) Mild vaginal bleeding

 

 

____    2.   A 28-year-old woman is a primipara who is pregnant with triplets, is at 18 weeks’ gestation, and is receiving regular prenatal care. The nurse identifies a risk for preterm labor related to which factor?

1) The patient’s age
2) 18 weeks’ gestation
3) Multiple gestations
4) Previous obstetric history

 

 

____    3.   The nurse questions an order to administer a tocolytic drug for which patient?

1) The patient under age 18
2) The patient with a history of multiple gestations
3) The patient who is 2 cm dilated
4) The patient with acute vaginal bleeding

 

 

____    4.   The experienced nurse recognizes that a graduate nurse needs guidance in caring for a woman at 38 weeks’ gestation with premature rupture of membranes when the graduate nurse is seen preparing to do what?

1) Fetal monitoring
2) Vital signs
3) Provide support and education
4) Conduct a cervical examination

 

 

____    5.   A patient is approaching 42 weeks’ gestation and has been admitted for induction of labor. The patient tells the nurse she does not want an induction and prefers to wait for labor to begin naturally. Which is the nurse’s best response?

1) “Waiting for labor to begin naturally could result in the death of your baby.”
2) “The longer you wait, the bigger the baby gets and the harder delivery will be.”
3) “Complications for you and your baby increase after 42 weeks of gestation.”
4) “If you had controlled your weight gain during pregnancy, you might have gone into natural labor.”

 

 

____    6.   The nurse is caring for a woman who has been admitted with a diagnosis of polyhydramnios and recognizes which as the most likely cause?

1) Fetal kidney failure
2) Gastrointestinal blockage
3) Rupture of the membranes
4) Fetal demise

 

 

____    7.   A woman’s labor is not progressing, and the fetus is found to be in the breech position. Which of the seven Ps of labor is involved with this woman’s failure to progress?

1) Presentation
2) Passenger
3) Passage
4) Powers

 

 

____    8.   A laboring patient’s water breaks, and the umbilical cord protrudes from the vagina. The nurse immediately places the patient in the Trendelenburg position. Which of the seven Ps is most impacted?

1) Passage
2) Pain
3) Powers
4) Position

 

 

____    9.   The fetus of a laboring patient is found to be in a breech position, and the nurse prepares the patient for a Cesarean section. The patient asks, “Can’t I try to deliver vaginally?” Which is the nurse’s best response?

1) “If the fetus has CPD, it could result in serious complications for you and the baby.”
2) “A fetus in the breech position causes labor to progress more slowly.”
3) “We’ll have to talk to the delivering provider to see if that is even possible.”
4) “When the fetus is breech, a Cesarean section is the safest choice for you and the baby.”

 

 

____  10.   The nurse is caring for a woman with suspected macrosomia. Which assessment finding best indicates the ability to deliver vaginally?

1) Cervical dilation at 10 cm
2) Fetus at +3 station
3) 100% effacement
4) Fetus at +1 station

 

 

____  11.   A laboring woman’s membranes rupture, and the umbilical cord prolapses. The nurse notifies the provider and prepares the patient for an immediate Cesarean section. The patient asks, “Why is a Cesarean section necessary?” Which is the nurse’s best response?

1) “It is our policy to always perform a Cesarean section when there is a prolapsed cord.”
2) “The baby could die if we don’t rush to deliver it, and a Cesarean section is the fastest method.”
3) “A Cesarean section is needed to save your life and prevent the risk of hemorrhaging.”
4) “The baby cannot be born vaginally without crimping off blood supply through the cord.”

 

 

____  12.   The nurse identifies which client as being at highest risk for placental abruption?

1) The client with hypertension
2) The client who reports drinking one beer 2 months ago
3) The client who uses marijuana
4) The client delivering triplets

 

 

____  13.   The nurse admits a patient who reports a desire to push. A quick assessment shows crowning of the fetal head. Which is the nurse’s priority action?

1) Running to the nursing station and calling the provider
2) Hurrying to the supply room for a precipitous delivery pack
3) Washing the hands, applying gloves, and cleansing the perineum
4) Remaining calm and staying with the patient while calling for help

 

 

____  14.   The nurse recognizes which patient is at risk for delivering an infant with shoulder dystocia?

1) The patient in premature labor
2) The patient with fetal macrosomia
3) The patient whose labor has been induced
4) The patient with hypertension

 

 

____  15.   The nurse admits a woman in labor after a motor vehicle accident that also involved her 14-month-old child. Fetal monitoring shows a nonreassuring fetal heart rate pattern with variable and late decelerations. Maternal examination reveals uterine tenderness and constant abdominal pain. After notifying the provider, which is the nurse’s priority of care?

1) Encouraging the patient to begin pushing
2) Obtaining a precipitous delivery pack
3) Initiating an IV with an 18-gauge catheter
4) Cleansing the perineum

 

 

____  16.   The postpartum nurse finds a patient who delivered 15 hours ago in shock with hypotension and tachycardia. Perineal assessment reveals hemorrhage and a mass protruding from the vagina. Upon reviewing the woman’s medical record, the nurse recognizes which risk factor for this event?

1) Precipitous delivery
2) Premature delivery
3) Multiple pregnancy
4) Placenta accreta

 

 

____  17.   The nurse examines a patient with postpartum hemorrhaging. Which assessment finding indicates placenta accreta rather than retained placenta?

1) Severe lower abdominal pain
2) Heavy vaginal bleeding
3) Elevated heart rate and hypotension
4) Pale mucous membranes and nailbeds

 

 

____  18.   A laboring patient becomes severely hypoxic and hypotensive, has altered mental status, and begins to have seizures. Which is the priority nursing intervention?

1) Administering oxygen
2) Initiating the rapid response team
3) Providing emotional support for patient and family
4) Administering IV fluids

 

 

____  19.   The nurse reviews a plan of care and sees the nursing diagnosis of Fear Related to Uncertainty of Pregnancy Outcome. Which priority nursing intervention should the nurse include when caring for this patient?

1) Reinforcing teaching provided to the patient by the provider and registered nurse
2) Providing information both verbally and in writing for the patient to refer to
3) Monitoring the patient and fetus for any nonreassuring signs and symptoms
4) Encouraging the participation of the support person in providing care

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  20.   The nurse is caring for a patient who delivered at 22 weeks’ gestation and experienced a fetal demise when the newborn could not be resuscitated in the delivery room. Which actions will the postpartum nurse include in the immediate plan of care for this family? (Select all that apply.)

1) Clean and dress the baby
2) Allow the family to hold the baby
3) Obtain footprints and pictures of the baby
4) Encourage the parents to cry over their loss
5) Connect the family to a support group

 

Chapter 12: Birth-Related Procedures

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which patient does the nurse recognize as not an appropriate candidate for amniotomy?

1) The woman who is at 41 weeks’ gestation
2) The woman with a fetus in the breech presentation
3) The woman with a history of hypertension
4) The woman with a history of precipitous delivery

 

 

____    2.   Which assessment finding is most important for the nurse to report immediately after the performance of an amniotomy?

1) Temperature of 37.6°C
2) Clear, odorless amniotic fluid
3) Abnormal fetal heart rate (FHR) pattern
4) Leakage of clear fluid from the vagina

 

 

____    3.   Which patient does the nurse recognize as a candidate for an amnioinfusion?

1) The woman who is postterm
2) The woman with multiple gestations
3) The woman with oligohydramnios
4) The woman carrying a fetus with a neural tube defect

 

 

____    4.   After a successful external cephalic version, the patient says, “Oh good! Now I won’t have to worry about having a Cesarean section!” Which teaching should the nurse provide this patient in response to this comment?

1) The fetus can drift back into an abnormal presentation.
2) There is no reason to worry about having a Cesarean section.
3) Potential complications following the procedure
4) Need to drink plenty of fluids for the next 24 hours

 

 

____    5.   A patient is 39 weeks pregnant and is admitted for induction of labor. Her Bishop score is 2. Which teaching does the nurse prepare for this patient?

1) Explain the process of inducing labor
2) Describe the fetal monitoring equipment
3) Explain the importance of monitoring fetal activity
4) Explain the need for chemical or mechanical cervical ripening

 

 

____    6.   A patient’s cervix is 2 cm dilated and 40% effaced, the fetal head is in the 0 station, and the consistency of the cervix is medium and is in the midposition. On the basis of the calculated Bishop score, how does the nurse interpret these findings?

1) The patient’s cervix is ripe and ready for induction.
2) The patient’s cervix is ripening, but readiness for induction is questionable.
3) Induction could be attempted, but cervical ripening is questionable.
4) The patient’s cervix is not ripe, and induction should not be initiated at this time.

 

 

____    7.   Which method of cervical ripening and induction of labor does the nurse consider safest and least likely to result in complications?

1) Insertion of a transcervical Foley catheter
2) Application of prostaglandin gel
3) Administration of Prepidil Endocervical Gel
4) Infusion of oxytocin (Pitocin)

 

 

____    8.   Which outcome is most appropriate for a nursing diagnosis of Risk for Injury in a patient whose labor is induced?

1) Demonstrates and verbalizes reduced anxiety
2) Verbalizes understanding of the process of labor induction
3) Verbalizes readiness to become a mother
4) Maintains a good labor pattern with a reassuring FHR pattern

 

 

____    9.   During the induction process, a patient frequently asks, “What are you doing now?” or “What is that for?” Which nursing diagnosis is most appropriate for this patient?

1) Knowledge Deficit related to induction of labor
2) Fear/Anxiety
3) Risk for Injury
4) Altered Mental Status

 

 

____  10.   What will the nurse instruct the patient to do when the provider begins to apply traction to the vacuum extractor?

1) Hold her breath and count to 10
2) Push with the contraction
3) Turn to her left side
4) Pant to avoid pushing

 

 

____  11.   Which patient does the nurse identify as likely to require a Cesarean delivery?

1) Postterm
2) O-negative blood type
3) Active genital herpes
4) 35 weeks’ gestation

 

 

____  12.   Which patient does the nurse assess as most likely to be able to delivery vaginally rather than requiring a Cesarean delivery?

1) Active genital herpes
2) Fetal macrosomia
3) Multiple gestations
4) History of previous Cesarean section

 

 

____  13.   Which assessment data will the nurse obtain from a patient who is being prepared for a Cesarean section?

1) Cervical dilation and effacement
2) Obtain a signed consent form
3) Diet history for the past 8 hours
4) Insert an indwelling catheter

 

 

____  14.   Which medication is contraindicated immediately prior to performance of a Cesarean section?

1) Cefazolin 1 g IV
2) Famotidine 20 mg IV
3) Fentanyl 100 mcg IV
4) Citric acid-sodium citrate solution 30 mL PO

 

 

____  15.   When a patient is prepared for discharge post-Cesarean section, which teaching does the nurse provide?

1) Plan to be in the hospital for 3 to 5 days.
2) Arrange for help at home.
3) Keep hair on the lower abdomen and pubis clipped.
4) Avoid unnecessary activity for 2 weeks.

 

 

____  16.   Which teaching should the patient scheduled for a Cesarean birth receive during a routine visit with the provider 2 weeks prior to hospital admission?

1) Pack for 3 to 5 days in the hospital.
2) Obtain preoperative laboratory work.
3) Sign a consent for the operative procedure.
4) Maintain good hydration.

 

 

____  17.   The nurse assesses which patient as having the best chance of a successful vaginal birth after a Cesarean section?

1) The woman whose first and third children were born vaginally
2) The woman with well-controlled gestational diabetes
3) The woman whose last child is 12 months old and was born by Cesarean section
4) The woman requiring induction of labor 4 years after a Cesarean section

 

 

____  18.   When caring for a woman undergoing a trial of labor after Cesarean (TOLAC), the nurse most carefully observes for signs of what?

1) Macrosomia
2) Failure to progress
3) Anxiety
4) Uterine rupture

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   An immediate Cesarean section will need to be performed if the nurse assesses which signs or symptoms in a woman attempting vaginal birth after a prior Cesarean section? (Select all that apply.)

1) A popping sensation reported by the patient
2) Acute, continuous abdominal pain
3) Repetitive or prolonged fetal heart rate decelerations
4) Slow labor progression
5) Vaginal bleeding

 

 

____  20.   Prior to discharging a patient, following cephalic version, which teaching does the nurse provide? (Select all that apply.)

1) Teach the patient how to monitor for fetal activity and when to call the provider.
2) Teach the patient how to monitor the fetal heart rate and when to call the provider.
3) Teach the patient the signs of the rupture of membranes and when to return to the hospital.
4) Teach the patient the signs and symptoms of labor and when to return to the hospital.
5) Teach the patient the importance of receiving RhoGAM prior to delivery.

 

Chapter 13: Physiological and Behavioral Adaptations During the Postpartum Period

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse examines a postpartum woman who is 1 day postdelivery. Which finding does the nurse consider abnormal?

1) Fundus 1 cm below the umbilicus
2) Bright red lochia
3) Dilated cervix
4) Reduced fibrinogen levels

 

 

____    2.   While reviewing laboratory values, the nurse sees a postpartum patient’s white blood cell count is 26,699 mg/dL, and her neutrophil count is also elevated. Which is the nurse’s priority action?

1) Assessing the episiotomy for signs of infection
2) Notifying the RN and/or provider
3) Continuing to monitor laboratory findings
4) Obtaining STAT vital signs

 

 

____    3.   When does the nurse expect to be unable to palpate the uterus in a postpartum patient?

1) Immediately after delivery
2) 5 days postdelivery
3) 1 week postdelivery
4) 2 weeks postdelivery

 

 

____    4.   Which events after delivery of the placenta cause the uterus to contract and begin shrinking to nonpregnant size?

1) Reduced estrogen and progesterone levels
2) Reduced estrogen and oxytocin levels
3) Reduced progesterone and oxytocin levels
4) Estrogen, progesterone, and oxytocin levels decline.

 

 

____    5.   The nurse examines a woman’s lochia and notices excessive bleeding. Which is the nurse’s priority action?

1) Assessing for a full bladder
2) Placing the patient in the Trendelenburg position
3) Massaging the uterus
4) Encouraging the woman to breastfeed

 

 

____    6.   A woman reports she has not urinated since delivering 8 hours ago and says she has no urge to void despite drinking adequate fluids postpartum. The nurse attributes this to what?

1) The woman was dehydrated and has not fully hydrated yet to produce urine.
2) The woman’s bladder tone is reduced, and she does not feel the urge to urinate.
3) The bladder has more room to expand and can hold more urine because of a smaller uterus.
4) The woman is experiencing a release of epinephrine, causing absence of bladder sensation.

 

 

____    7.   The nurse is caring for a woman who delivered her third child 2 days ago and who says, “I am having pain; it feels like labor pain. I never experienced this with my other children, and it is worse when I breastfeed.” Which is the nurse’s priority response?

1) Further assess the pain’s location, intensity, and frequency
2) Explain the purpose of afterpains and reassure the patient
3) Immediately obtain vital signs and monitor vital signs every 15 minutes
4) Administer a narcotic analgesic to control pain

 

 

____    8.   Which patient does the nurse anticipate is most likely to experience afterpains?

1) The woman who had a precipitous delivery
2) The woman who delivered a preterm infant
3) The primipara who had a difficult pregnancy
4) The multipara who delivered her fifth child

 

 

____    9.   The nurse working in a women’s clinic admits a patient who is almost 6 weeks postpartum and describes a yellow-white vaginal drainage. The nurse interprets this as indicating what?

1) Bacterial infection
2) Retained placenta
3) Expected lochia progression
4) Fungal infection

 

 

____  10.   The ICU nurse is caring for a postpartum patient who experienced complications. Which color of lochia does the nurse expect to find on the fifth day postpartum?

1) Bright red
2) Dark red
3) Pink
4) Yellow-white

 

 

____  11.   A breastfeeding mother says, “One good thing about breastfeeding is that I won’t have to worry about getting pregnant till I stop.” Which information will the nurse provide to this patient?

1) Ovulation and menstruation may be delayed by breastfeeding, but not always.
2) Ovulation will resume as early as 27 days after delivery.
3) Ovulation will resume within 30 days of stopping breastfeeding.
4) By breastfeeding even once a day, she can delay ovulation.

 

 

____  12.   Which statement by a postpartum patient indicates teaching regarding menses and contraception has been understood?

1) “I don’t have to worry about getting pregnant until I get my first menstrual period.”
2) “Because I am breastfeeding, I don’t have to worry about getting pregnant until I quit.”
3) “I should resume using my diaphragm as soon as I resume sexual activity.”
4) “I should use a contraceptive when I resume sexual activity to avoid pregnancy.”

 

 

____  13.   The nurse is making a home-care visit when the newborn starts to cry. The new mother smiles and says, “That’s his hungry cry.” The nurse interprets this as indicating the mother is in which phase of maternal role attainment?

1) Taking-in phase
2) Taking-hold phase
3) Letting-go phase
4) Transitioning from taking-in to taking-hold phase

 

 

____  14.   Which observed behavior arouses the nurse’s concern as an indication the mother is not bonding with her baby?

1) The mother expresses fear she will hurt the baby because she doesn’t know what to do.
2) The mother stares at the baby’s face and touches it only with her fingertips.
3) The mother does not want to hold the infant and asks to keep the baby in the nursery.
4) The mother asks many questions about self-care and newborn care.

 

 

____  15.   Which behavior observed by the nurse indicates a new mother is beginning to bond with her newborn?

1) Takes the en face position
2) Tells the nurse about her labor experience
3) Needs reassurance of her ability to be a good mother
4) Asks to keep the baby in the nursery overnight so she can sleep

 

 

____  16.   The nurse enters a postpartum patient’s room and finds the father staring at the newborn in the bassinet with a contemplative look on his face. How should the nurse interpret this behavior?

1) The father may be a danger to the baby.
2) The father feels resentful toward the baby.
3) The father is uncertain about being a father.
4) The father is bonding with the baby.

 

 

____  17.   Which is the best intervention for the nurse to use to promote eye contact between the mother and newborn?

1) Pointing out characteristics of the newborn such as eye color, milia, and other facial features
2) Encouraging the mother to change the baby’s diaper
3) Encouraging the mother to hold the baby
4) Taking the baby to the nursery and allowing the mother to rest

 

 

____  18.   It is time for a newborn to have blood collected for the newborn screening. How does the nurse turn this into a bonding opportunity for the mother?

1) Perform the test in the mother’s room and encourage her to comfort the newborn afterward
2) Take the baby to the nursery for the test to avoid upsetting the mother
3) Explain the bandage on the baby’s foot when returning the baby to the mother’s room
4) Perform the test without mentioning it to the mother to reduce anxiety

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   A new mother asks the nurse what she can do to foster attachment between the newborn and her 8-year-old daughter. Which recommendations should the nurse make? (Select all that apply.)

1) Have the child visit in the hospital
2) Let the child help care for the baby as he or she is able
3) Have Mom spend some time alone with the child
4) Keep the baby away from the child as much as possible
5) Anticipate unpredictable and uncomplimentary statements about the baby

 

 

____  20.   Which behaviors observed by the nurse indicate that a postpartum patient is in the taking-in phase? (Select all that apply.)

1) Introduces information about her labor into every conversation
2) Strokes the baby with just the tips of her fingers
3) Asks the nurse to keep the baby in the nursery so she can sleep
4) When caring for the newborn, often asks the nurse, “Did I do that right?”
5) Spontaneously begins to cry with no explanation for why she is crying

 

Chapter 14: Assessment and Care of the Family After Birth

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   After the nurse assesses a woman’s uterus and finds it soft and boggy with no improvement after massage, which is the priority intervention?

1) Notifying the provider
2) Assessing the bladder
3) Inserting a catheter
4) Having the woman breastfeed

 

 

____    2.   The nurse caring for a patient during the first hour after delivery needs to notify the provider when which condition is assessed?

1) Several small blood clots on the peripad
2) Saturation of two peripads over the hour
3) Passing a large clot the size of a fist
4) Yellow-white drainage from the nipples

 

 

____    3.   The nurse performs a focal postpartum assessment using the BUBBLE LE mnemonic. Which assessment finding is incorrect to document as part of this examination?

1) Breasts firm and tender; patient reports sore nipples
2) Fundus 2 cm below umbilicus, firm
3) Lochia pink, small amount of drainage
4) Pulse strong and regular at rate of 84 beats per minute

 

 

____    4.   While performing a BUBBLE LE postpartum assessment, the nurse notes a raised area just above the symphysis pubis. Which is the nurse’s priority action?

1) Completing the assessment and documenting the findings
2) Notifying the provider and obtaining orders
3) Assisting the patient to the bathroom
4) Massaging the uterus until it becomes firm

 

 

____    5.   The nursing instructor observes a student providing care to an adolescent postpartum patient. Which statement made by the student indicates the need for further teaching?

1) “Let me show you a way to hold the baby when you’re giving him a bath.”
2) “Do you want your little friend to stay while you breastfeed?”
3) “You’re going to be a great mother because you really want to learn.”
4) “Do you have any questions or need help with anything?”

 

 

____    6.   A new adolescent mother asks the nurse how to bathe her baby. Which is the nurse’s best approach to teach her this procedure?

1) Have the new mother bathe the baby while the nurse talks her through the process
2) Explain the procedure using pictures and diagrams
3) Give the new mother a brochure and tell her to ask if she has any questions
4) Let the new mother watch the nurse bathe the baby and then give a return demonstration tomorrow

 

 

____    7.   What is the nurse’s role when caring for a mother who is relinquishing her infant for adoption?

1) Discouraging her from holding or seeing her infant
2) Encouraging her to see the infant and take pictures
3) Avoiding discussion about the baby or her labor unless she brings it up
4) Respecting the mother’s choices regarding the baby

 

 

____    8.   A postpartum patient who plans to relinquish her baby for adoption says, “I’m having second thoughts. Maybe I should keep the baby.” Which is the nurse’s best response?

1) “If you aren’t sure, you should keep the baby until you make up your mind.”
2) “You’ve made a promise to the adopting parents, and it’s too late to change your mind.”
3) “It is such a difficult decision to make. You must feel pulled in two directions.”
4) “I can hear the indecision in your voice. Would you like to talk about it?”

 

 

____    9.   After a patient has been taught postpartum self-care, which statement by the mother indicates the need for further teaching?

1) “I will make an appointment with my provider to have my episiotomy stitches removed next week.”
2) “I can take acetaminophen and use warm sitz baths to control discomfort at my episiotomy site.”
3) “I’ll keep a squirt bottle filled with warm water in the bathroom to cleanse with each time I urinate.”
4) “I will wear my nursing bra at all times, even when I go to bed, as long as I continue to nurse the baby.”

 

 

____  10.   A postpartum patient is experiencing early postpartum hemorrhage. Which is the nurse’s priority intervention?

1) Notifying the provider
2) Performing fundal massage
3) Expressing clots from the boggy uterus
4) Weighing peripads and linens to determine blood loss

 

 

____  11.   The nurse is caring for a postpartum patient experiencing hemorrhage that has not responded to massage, compression, or medications. Which should the nurse prepare for?

1) Moving the patient to the operating room (OR)
2) Bimanual compression of the uterus
3) Pelvic examination with visualization
4) Administration of whole blood

 

 

____  12.   The nurse assesses a postpartum patient’s perineum and notes a discoloration and bulging of the vagina that is very tender to the touch. Which symptom reported by the patient is the result of this assessment finding?

1) “When I urinate, it burns until after I finish cleansing with the water bottle.”
2) “I am bleeding much less today than I did yesterday, and it’s pink rather than red now.”
3) “I have the constant feeling of needing to have a bowel movement, but I can’t do anything.”
4) “I am so tired. I just want to sleep whenever I don’t have visitors or the baby with me.”

 

 

____  13.   What does the nurse do to reduce the size of a newly discovered 3-cm hematoma and encourage reabsorption of the clot?

1) Administer analgesics
2) Apply ice
3) Encourage warm sitz baths
4) Prepare the patient for the OR

 

 

____  14.   The nursing assessment of a postpartum patient indicates a temperature of 39.4°C, lower left abdominal tenderness, and foul-smelling lochia. Which independent nursing intervention does the nurse begin before notifying the provider?

1) Administering IV fluids
2) Administering antipyretics
3) Encouraging fluid intake
4) Administering analgesics

 

 

____  15.   Which statement made by a patient at high risk for venous thrombosis indicates the need for further teaching?

1) “I have to continue wearing compression stockings for only the first 2 weeks after delivery.”
2) “I will not start smoking again because that will increase the risk of a blood clot developing.”
3) “I will try to remain active and avoid prolonged periods of sitting or resting in bed.”
4) “I will report any pain, swelling, or redness in my legs to my provider.”

 

 

____  16.   When the nurse reviews a patient’s past history, which finding is identified as placing the patient at greater risk for postpartum psychosis?

1) Depression
2) Bipolar disorder
3) Obsessive-compulsive disorder
4) Previous postpartum depression

 

 

____  17.   Which new mother is not at increased risk for postpartum depression?

1) The mother who relinquishes her baby
2) The adolescent mother
3) The mother with a history of previous postpartum depression
4) The mother who delivered by scheduled Cesarean section

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  18.   A new mother is having difficulty getting the baby to latch on properly, resulting in cracked, sore nipples. The nurse recognizes this as a risk factor for what? (Select all that apply.)

1) Mastitis
2) Blocked milk ducts
3) Milk stasis
4) Inability to breastfeed
5) Breast abscess

 

 

____  19.   What does the nurse assess as part of the BUBBLE LE mnemonic? (Select all that apply.)

1) Episiotomy or abdominal incision
2) Bonding and attachment
3) Pain
4) Circulation in the legs
5) Gait

 

 

____  20.   Which actions performed by the nurse demonstrate appropriate uterine massage for the postpartum patient? (Select all that apply.)

1) Positioning one hand at the fundus of the uterus
2) Pressing down until the fundus is palpated as a firm, hard, globular mass
3) Noting the position of the fundus
4) Placing one hand at the base of the uterus
5) Calling and informing the provider of the uterine location

 

Chapter 15: Physiological and Behavioral Adaptations of the Newborn

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which action does the nurse take to reduce the newborn’s evaporative heat loss?

1) Placing the newborn on a warm surface
2) Keeping the room temperature warm
3) Keeping the newborn away from cool objects
4) Drying the infant thoroughly after birth

 

 

____    2.   After a newborn has been bathed, which action performed by the nurse indicates a need for further teaching about maintaining the baby’s thermoregulation?

1) The newborn is placed in a clean bassinet.
2) The newborn is thoroughly dried.
3) The newborn is dressed and swaddled in a blanket.
4) A hat is placed on the newborn’s head.

 

 

____    3.   The nurse needs to draw blood via heel stick for a newborn screening examination. How can the nurse use understanding of the newborn’s heat production physiology to promote blood collection?

1) By applying a warm pack to the heel before attempting to draw blood
2) By wrapping the baby in a blanket with a hat
3) By placing the baby under a radiant warmer
4) By elevating the head of the bassinet

 

 

____    4.   The nurse admits a newborn to the admission nursery and prepares to bathe the baby for the first time after assessing what?

1) Drying of the umbilical cord
2) Two hours since last eating
3) Stable temperature for 2 hours
4) Temperature 36.2°C axillary on radiant warmer

 

 

____    5.   The nurse accepts a newborn from the provider after delivery. Which is the priority intervention?

1) Placing the infant skin-to-skin with the mother
2) Drying the newborn
3) Placing a hat on the baby’s head
4) Placing the baby on the radiant warmer

 

 

____    6.   When caring for a newborn born by Cesarean section, the nurse recognizes the increased risk for respiratory distress because the baby did not experience which external stimuli?

1) Chest squeeze
2) Stimulation of skin sensors
3) Cutting of the umbilical cord
4) Decreased pH

 

 

____    7.   Immediately after the umbilical cord is cut, the newborn has a weak, shallow cry. Which is the nurse’s priority action to promote breathing?

1) Assessing vital signs
2) Placing the newborn skin-to-skin with the mother
3) Flicking the newborn’s heels
4) Drying the newborn vigorously

 

 

____    8.   The nurse reviews the laboratory results of a 1-hour-old newborn. Which finding does the nurse need to report to the provider immediately?

1) Elevated hemoglobin and hematocrit – 17 g/100 mL and 48%
2) Elevated white blood cell count – 17,000
3) Prolonged clotting time
4) Elevated bilirubin

 

 

____    9.   The nurse is caring for an 18-hour-old newborn who has not voided for the first time yet. Which is the nurse’s priority action?

1) Notifying the provider immediately
2) Pressing on the bladder to prevent urine retention
3) Encouraging frequent breastfeeding
4) Documenting and continuing monitoring

 

 

____  10.   The nurse observes a mother bottle feeding her newborn and recognizes further teaching is needed when the mother does what?

1) Holds the bottle upright to fill the nipple
2) Holds the baby flat in her arms after the feeding
3) Feeds the baby until he stops sucking
4) Burps the baby halfway through the feeding

 

 

____  11.   Which intervention is most effective for the nurse to perform to promote elimination of conjugated bilirubin?

1) Administering IV fluid
2) Encouraging frequent feeding
3) Discourage breastfeeding
4) Administering packed blood cells

 

 

____  12.   What is the liver’s job related to bilirubin?

1) Changing unconjugated bilirubin to conjugated bilirubin
2) Slowing the breakdown of red blood cells
3) Changing direct bilirubin to indirect bilirubin
4) Attaching bilirubin to albumin

 

 

____  13.   The nurse notes a newborn’s skin and sclera have taken on a yellow hue. Which finding does the nurse expect to see when reviewing the laboratory values?

1) Elevated red blood cell count
2) Elevated direct bilirubin
3) Elevated unconjugated bilirubin
4) Elevated serum albumin levels

 

 

____  14.   Which newborn is at lowest risk for elevated unconjugated bilirubin levels?

1) The newborn with significant bruising from a face presentation
2) The premature newborn
3) The newborn with O+ blood type, born to a mother with O- blood type
4) The baby born at 41 weeks’ gestation

 

 

____  15.   Normal physiological jaundice is assessed when the nurse observes what?

1) Lethargy, disinterest in feeding, and decreased urine output
2) Serum conjugated bilirubin of 3.2 mg/dL
3) Elevated unconjugated bilirubin at 12 hours of life
4) Serum total bilirubin of 7.2 mg/dL on day 4 of life

 

 

____  16.   A mother who is holding her 2-hour-old newborn says, “I don’t think she likes breastfeeding, but last time, when we were in the delivery room, she did really well.” Which is the nurse’s best response?

1) “After birth, babies go into a deep sleep, but when she wakes up, she’ll be hungry.”
2) “Your milk isn’t in yet. That is why she acts disinterested in eating.”
3) “You just need to wake her up so she’ll be alert and ready to eat.”
4) “Let me help you get her to latch on. Once she takes hold, she’ll be fine.”

 

 

____  17.   The nurse encourages bonding when a baby is in which stage of the sleep-wake cycle?

1) Light sleep
2) Drowsy
3) Alert
4) Active alert

 

 

____  18.   A mother says, “I changed his diaper, fed him, burped him, and he won’t stop crying. I even tried playing music for him and shaking this toy for him. What am I doing wrong?” Which is the nurse’s best response?

1) “Why don’t you try feeding him a little bit more?”
2) “Here, I’ll take him back to the nursery so you can rest.”
3) “Are you sure you burped him enough?”
4) “He may be overstimulated. Try snuggling him close.”

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  19.   Which changes in newborn circulation does the nurse anticipate immediately after the first lusty cry, prior to clamping of the umbilical cord? (Select all that apply.)

1) Closure of the ductus arteriosus
2) Closure of the ductus venosus
3) Closure of the foramen ovale
4) Increased blood flow to the lungs
5) Closure of the umbilical vessels

 

 

____  20.   Which assessment findings indicate the newborn is cold stressed and burning brown fat to produce heat? (Select all that apply.)

1) Hypoglycemia
2) Metabolic acidosis
3) Respiratory distress
4) Respiratory alkalosis
5) Irritability

 

Chapter 16: Assessment and Care of the Newborn

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term should the nurse use to describe the fine, downy hair that covers the forehead, ears, and body of the newborn?

1) Lanugo
2) Petechiae
3) Acrocyanosis
4) Vernix caseosa

 

 

____    2.   Which type of assessment should the nurse conduct to identify life-threatening problems when providing care to a newborn?

1) Initial
2) Baseline
3) Emergency
4) Problem-focused

 

 

____    3.   Which datum collected by the nurse is indicative of normal newborn vital signs?

1) Axillary temperature of 96.8°F (37°C)
2) Heart rate at rest of 180 beats per minute
3) Respiratory rate of 62 breaths per minute
4) Blood pressure of 90/60 mm Hg on day 1 of life

 

 

____    4.   Which is the nurse’s first action when conducting a head-to-toe assessment of a newborn?

1) Examining the newborn’s eyes
2) Assessing the newborn’s mouth
3) Observing the newborn’s skin color
4) Conducting an ear assessment of the newborn

 

 

____    5.   Which data noted by the nurse during the newborn skin assessment require a report to the registered nurse (RN) in charge of the shift?

1) Milia
2) Lanugo
3) Cyanosis
4) Nevus simplex

 

 

____    6.   The nurse is conducting a skin assessment for a newborn patient. Which data indicate a normal skin variation that requires no further intervention?

1) Melanocytic nevus on the left forearm
2) Nevus simplex on the nape of the neck
3) Hemangioma on the back that is 1 cm
4) Erythema toxicum neonatorum noted on the trunk

 

 

____    7.   Which data cause the nurse to document a caput succedaneum when conducting a newborn assessment?

1) Bruising of the scalp and extremities
2) Swelling of the head that does not cross the suture line
3) Bruising and swelling of the scalp that crosses the suture line
4) Swelling of the head that appears at day 2 of life

 

 

____    8.   Which assessment finding should the nurse anticipate for a male newborn as a result of exposure to maternal hormones?

1) Gynecomastia
2) Pseudomenstruation
3) Small and tight scrotum
4) Nocturnal emission

 

 

____    9.   Which reflex is considered normal during the newborn stage of development, but considered abnormal after 2 years of life?

1) Gag
2) Moro
3) Rooting
4) Babinski

 

 

____  10.   Which immunization(s) should the nurse plan to administer as part of normal newborn care prior to discharge?

1) Vitamin K
2) Erythromycin ointment
3) Hepatitis B
4) Measles, mumps, and rubella

 

 

____  11.   Which parental statement regarding newborn screening indicates correct understanding of the information presented by the nurse?

1) “My baby will have newborn screenings drawn periodically during the first year of life.”
2) “My baby will have to have his first newborn screenings completed during our first pediatrician visit.”
3) “Because my baby failed both the newborn hearing screens, he will need to be retested before we can take him home.”
4) “Because my baby didn’t start eating by mouth until today, we will wait until tomorrow for the newborn screening test.”

 

 

____  12.   Which statement regarding the New Ballard gestational assessment tool is accurate?

1) “This tool cannot be used to assess gestational age for newborns born before 30 weeks’ gestation.”
2) “This tool is used to assess gestational age on the basis of neurological activity only.”
3) “This tool is used to assess gestational age on the basis of physical activity only.”
4) “This tool is used to assess gestational age on the basis of six areas of neurological and physical activity.”

 

 

____  13.   When the licensed practical nurse (LPN) is drawing newborn blood via a heel stick, which action requires intervention by the RN?

1) Cooling the heel to increase circulation
2) Cleansing the heel with alcohol
3) Allowing the heel to dry
4) Using the outer aspect of the heel

 

 

____  14.   Which action by the nurse is inappropriate when performing the newborn bath in the nursery?

1) Using a pH-neutral cleanser
2) Scrubbing the vernix off the skin
3) Swaddling during immersion in the water
4) Ensuring the environment is free from drafts

 

 

____  15.   Which action should the nurse implement to enhance parental comfort during the discharge teaching process?

1) Establishing rapport
2) Demonstrating skills
3) Encouraging questions
4) Asking for a return demonstration

 

 

____  16.   Which nursing action enhances family-centered care during the discharge teaching process?

1) Stating a personal opinion when discussing circumcision
2) Asking the grandparents to leave when providing instruction
3) Including the newborn’s sibling in the educational session
4) Documenting the session in the medical record

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   During the discharge teaching process, which statements should the nurse include when teaching the parents of a newborn to enhance safety? (Select all that apply.)

1) “When riding in a car, your baby should be secured in a child safety seat in a rear-facing position for the first 12 months of life.”
2) “You should avoid trimming or filing your baby’s nails because this can increase the risk for injury.”
3) “Your baby requires two extra layers of clothing to stay warm during the winter months.”
4) “You should place your baby on the stomach to sleep in order to decrease the risk for SIDS.”
5) “Your baby may require assistance clearing the airway via the bulb syringe after spitting up.”

 

 

____  18.   Which disorders are assessed when conducting a newborn screening process? (Select all that apply.)

1) Genetic
2) Metabolic
3) Endocrine
4) Respiratory
5) Cardiovascular

 

 

____  19.   Which nursing actions enhance safety when providing newborn care? (Select all that apply.)

1) Placing the newborn on the back to sleep
2) Reporting newborn cyanosis to the health-care provider
3) Notifying the charge nurse of a newborn heart rate of 118 beats per minute
4) Placing an extra blanket on the newborn for an axillary temperature less than 97°F
5) Verifying the newborn’s identification with the mother’s band prior to administering medication

 

 

____  20.   The nurse is providing care to a newborn postcircumcision. Which actions by the nurse are appropriate? (Select all that apply.)

1) Using an approved scale to monitor for pain
2) Administering prescribed analgesics for a pain rating of 2
3) Documenting the first void in the medical record postprocedure
4) Teaching the parents to place petroleum jelly on the tip of the penis for 10 days
5) Placing a numbing cream on the tip of the penis for 24 hours

 

Chapter 17: Newborn Nutrition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term should the nurse use when documenting a new mother’s milk production in the medical record?

1) Lactoferrin
2) Lactogenesis
3) Galactosemia
4) Engorgement

 

 

____    2.   When determining a term newborn’s caloric needs, which should the nurse use?

1) 60 to 80 kcal/kg/day
2) 105 to 108 kcal/kg/day
3) 110 to 120 kcal/kg/day
4) 140 to 160 kcal/kg/day

 

 

____    3.   Which must occur for lactogenesis to occur?

1) A slow drop in estrogen level after childbirth
2) An increase in progesterone level prior to childbirth
3) An increase in prolactin with nipple stimulation
4) A dramatic drop in oxytocin level with nipple stimulation

 

 

____    4.   Which type of breast milk is produced in stage 1 of human milk production?

1) Foremilk
2) Colostrum
3) Hindmilk
4) Transitional milk

 

 

____    5.   Which statement regarding the advantages of breastfeeding should the nurse include in an educational session for a pregnant woman?

1) “Breastfeeding is economical.”
2) “Breastfeeding in public may cause embarrassment.”
3) “Certain medications may interfere with breastfeeding.”
4) “It may be necessary to wear breast pads because of leakage while breastfeeding.”

 

 

____    6.   Which patient condition contraindicates breastfeeding?

1) Maternal HIV
2) Newborn jaundice
3) Newborn prematurity
4) Maternal intake of antibacterial medications

 

 

____    7.   Which parental statement regarding newborn readiness to nurse indicates the need for further education?

1) “The rooting reflex indicates that my baby is ready to breastfeed.”
2) “When my baby makes hand-to-mouth movements, this indicates readiness for breastfeeding.”
3) “My baby will make tongue movements to indicate breastfeeding readiness.”
4) “My baby will initiate the palmar grasp when ready to breastfeed.”

 

 

____    8.   Which parental statement regarding latch-on during breastfeeding indicates the need for additional teaching by the nurse?

1) “I will cup my breast with my fingers to help my baby latch on while breastfeeding.”
2) “I should place my thumb on the bottom of my breast when helping my baby latch on during breastfeeding.”
3) “I should avoid covering the areola with my hand while assisting my baby to latch on during breastfeeding.”
4) “I should brush my nipple lightly across my baby’s lips to assist with latch-on during breastfeeding.”

 

 

____    9.   A nursing mother states, “I think my baby has developed nipple confusion.” Which question should the nurse ask to further assess the mother’s statement?

1) “How often are you changing your breast pads?”
2) “How many weeks have you been breastfeeding?”
3) “Are you offering both breasts each time you nurse?”
4) “Are you using the breast shield recommended by the lactation consultant?”

 

 

____  10.   Which data collected during a newborn wellness visit indicate the need for further intervention?

1) Losing 5% of the birth weight
2) Failing to gain back initial weight loss by day 7 of life
3) Having two bowel movements each day
4) Changing four wet diapers each day

 

 

____  11.   Which mother might benefit from bottle feeding rather than breastfeeding?

1) A mother diagnosed with epilepsy who takes medications that pass through the breast milk
2) A mother who will return to work 12 weeks after childbirth
3) A mother with inverted nipples who delivered by Cesarean section
4) A mother with two other small children at home

 

 

____  12.   Which parental statement indicates the need for further education related to formula preparation?

1) “Any unused formula should be thrown out after 24 hours.”
2) “I will add equal amounts of formula and water when using concentrated formula.”
3) “Ready-to-use formula can be further diluted if my baby experiences constipation.”
4) “Powder formula is mixed with tap water and poured in a bottle for feedings.”

 

 

____  13.   Which statement made by the mother of a bottle-feeding newborn necessitates the need for additional education related to safety?

1) “I use a cup of warm water to heat the formula prior to feedings.”
2) “I prop the bottle only if I need to multitask during feedings.”
3) “I always follow the instructions for mixing powdered formula.”
4) “I can begin to give my baby juice at 6 months of age.”

 

 

____  14.   Which parental action indicates the need for additional teaching related to bottle feeding?

1) Mixing rice cereal with formula and feeding it to the baby with a spoon
2) Providing juice through a bottle at 5 months of age
3) Allowing the baby to drink water at 9 months of age
4) Adding an equal amount of water and concentrated formula when mixing a bottle

 

 

____  15.   Which nursing action assists the mother of a newborn who wants to breastfeed?

1) Providing formula to the newborn in the nursery
2) Encouraging rooming-in during the hospital stay
3) Giving the newborn a pacifier between feedings
4) Encouraging bottle feeding overnight to allow for rest

 

 

____  16.   Which is a disadvantage of bottle feeding?

1) Purchasing formula for the first year of life
2) Pumping breast milk
3) Leaking breast milk
4) Having to avoid certain medications

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which maternal conditions will cause the nurse to educate a new mother that formula, not breast milk, should be used for newborn nutrition? (Select all that apply.)

1) Hypertension (HTN)
2) Bipolar disorder (BD)
3) Diabetes mellitus (DM)
4) Active tuberculosis (TB)
5) HIV

 

 

____  18.   Which statements regarding the disadvantages of breastfeeding should the nurse include in an educational session for a pregnant woman? (Select all that apply.)

1) “Breastfeeding is economical.”
2) “Breastfeeding in public may cause embarrassment.”
3) “Certain medications may interfere with breastfeeding.”
4) “It may be necessary to wear breast pads because of leakage while breastfeeding.”
5) “Breastfeeding provides your baby with protection from certain illnesses and diseases.”

 

 

____  19.   Which parental statements regarding newborn readiness to nurse indicate correct understanding of the information provided? (Select all that apply.)

1) “The rooting reflex indicates that my baby is ready to breastfeed.”
2) “When my baby makes hand-to-mouth movements, this indicates readiness for breastfeeding.”
3) “My baby will make tongue movements to indicate breastfeeding readiness.”
4) “My baby will initiate the palmar grasp when ready to breastfeed.”
5) “The Babinski reflex indicates that my baby is ready to breastfeed.”

 

 

____  20.   Which parental statements indicate correct understanding of the characteristics and benefits of colostrum? (Select all that apply.)

1) “It contains high levels of protein.”
2) “It will provide my baby with protection against certain diseases.”
3) “It has a laxative effect, facilitating the meconium stools.”
4) “It contains high levels of both carbohydrates and fats.”
5) “It has a high water content, decreasing the risk for dehydration.”

 

Chapter 18: Newborn at Risk: Conditions Present at Birth

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term should the nurse use to document decreased fetal growth due to impaired perfusion of the placenta?

1) Low birth weight
2) Premature neonate
3) Small for gestational age (SGA)
4) Intrauterine growth restriction (IGR)

 

 

____    2.   The nurse is providing care to a newborn whose blood glucose level is 25 mg/dL. Which term should the nurse use to document this datum in the medical record?

1) Hypothermia
2) Hyperthermia
3) Hypoglycemia
4) Hyperglycemia

 

 

____    3.   The nurse is providing care to several patients on a labor and delivery unit. Which patient’s delivery requires that the newborn intensive care team be present at the time of birth?

1) A 25-year-old patient with a history of depression
2) A 30-year-old patient with a history of anxiety
3) A 35-year-old patient with a history of kidney stones
4) A 40-year-old patient with a history of hypertension

 

 

____    4.   Which data collected during the health history of a laboring patient increase the risk of delivering an SGA newborn?

1) Blood pressure level of 110/60 mm Hg
2) Serum glucose level of 85 mg/dL
3) Weight gain of 12 lb (5.5 kg)
4) Pulse rate of 90 beats per minute

 

 

____    5.   Which data collected during the newborn admission process support the documentation of an SGA neonate?

1) Abundant lanugo
2) Elastic ear cartilage
3) Thin umbilical cord
4) Lack of posterior sole creases

 

 

____    6.   Which complication should the nurse monitor for when providing care to a large-for-gestational-age (LGA) newborn?

1) Hypothermia
2) Hyperglycemia
3) Fractured clavicle
4) Uncontrolled hypertension

 

 

____    7.   Which data collected during the pregnant patient’s health history interview indicate the need for the nurse to closely monitor for premature labor?

1) Single gestation pregnancy
2) Birth of first child at 37 weeks’ gestation
3) History of cigarette use during pregnancy
4) Urinary tract infection treated with 7 days of antibiotics

 

 

____    8.   Which complication associated with prematurity manifests with apnea, decreased reflexes, a weak suck, and seizure activity?

1) Neonatal jaundice
2) Intraventricular hemorrhage
3) Patent ductus arteriosus (PDA)
4) Necrotizing enterocolitis (NEC)

 

 

____    9.   Which clinical manifestations should the nurse anticipate when providing care to a postterm newborn?

1) Vernix and lanugo
2) Partially formed fingernails
3) Abundant subcutaneous tissue
4) Meconium-stained umbilical cord

 

 

____  10.   Which data for a pregnant patient in labor indicate the need to closely monitor the newborn for polycythemia after birth?

1) Hyperglycemia during the third trimester
2) Hypoglycemia during the second trimester
3) Blood glucose that is well controlled during the first trimester
4) Blood glucose that is poorly controlled during the first trimester

 

 

____  11.   Which condition should the nurse closely monitor for when providing care to a neonate whose mother is diagnosed with DM?

1) Hypoxia
2) Hypokalemia
3) Hyperglycemia
4) Hyperbilirubinemia

 

 

____  12.   The nurse is providing care to a newborn in the general nursery. The newborn is exhibiting symptoms associated with neonatal abstinence syndrome (NAS). Which is the priority nursing action?

1) Administering prescribed morphine
2) Assessing the neonate’s blood glucose level
3) Monitoring IV fluid administration
4) Transferring the neonate to the intensive care unit

 

 

____  13.   Which nursing intervention is appropriate when providing care to a newborn exposed to HIV in utero?

1) Obtaining a complete blood count
2) Consulting with a pediatric infectious control specialist
3) Strict maintenance of transmission-based precautions
4) Advising the mother to bottle feed rather than breastfeed

 

 

____  14.   When planning care for a newborn who was exposed to HIV in utero, which member of the health-care team should the nurse include in an interdisciplinary care conference?

1) Physical therapist
2) Endocrine specialist
3) Occupational therapist
4) Infectious control specialist

 

 

____  15.   Which term should the nurse use when documenting the care provided to a neonate born at 38 weeks and 1 day of gestation?

1) Preterm
2) Full term
3) Late term
4) Early term

 

 

____  16.   Which medication prescription should the nurse anticipate when providing care to a newborn exposed to HIV in utero?

1) Caffeine
2) Morphine
3) Zidovudine
4) Phenobarbital

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which complications should the nurse monitor for when providing care to an LGA newborn? (Select all that apply.)

1) Hypoglycemia
2) Respiratory distress
3) Meconium aspiration
4) Palpable abdominal mass
5) Hypoactive bowel sounds

 

 

____  18.   Which complications should the nurse monitor for when providing care to a premature newborn suspected of having NEC? (Select all that apply.)

1) Hematochezia
2) Hypoglycemia
3) Respiratory distress
4) Palpable abdominal mass
5) Hypoactive bowel sounds

 

 

____  19.   Which clinical manifestations support the diagnosis of polycythemia for a neonate born to a diabetic mother? (Select all that apply.)

1) Hematuria
2) Ruddy skin
3) Poor feeding
4) Hematochezia
5) Hyperglycemia

 

 

____  20.   Which parental actions indicate correct understanding of the care required for a newborn diagnosed with NAS? (Select all that apply.)

1) Swaddling the neonate
2) Avoiding strong fragrances
3) Providing a calm environment
4) Allowing the neonate to “cry it out”
5) Handling the neonate as often as possible

 

Chapter 19: Newborn at Risk: Birth-Related Stressors

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term should the nurse use to describe gas exchange in which no oxygen is reaching the cells?

1) Anoxia
2) Hypoxia
3) Asphyxia
4) Hypercapnia

 

 

____    2.   To decrease the risk for birth asphyxia, which maternal condition should the nurse monitor for during labor and delivery?

1) Anemia
2) Hypertension
3) Precipitous childbirth
4) Too much oxygen during childbirth

 

 

____    3.   Which newborn condition requires the nurse to closely monitor for the development of respiratory distress syndrome (RDS)?

1) Postterm birth
2) Precipitous delivery
3) Hyperbilirubinemia
4) Meconium aspiration

 

 

____    4.   Which data cause the licensed practical nurse (LPN) to notify the registered nurse (RN) when providing care for a newborn patient?

1) Eupnea
2) Acrocyanosis
3) Crying with a blood draw
4) Grunting with expirations

 

 

____    5.   Which nursing intervention should be included in the plan of care for a newborn experiencing transient tachypnea?

1) Encouraging breastfeeding
2) Monitoring ordered IV fluids
3) Providing stimulation every 30 minutes
4) Maintaining oxygen saturation level above 95%

 

 

____    6.   Which data collected during the newborn’s physical assessment support the current diagnosis of meconium aspiration syndrome?

1) Bradypnea
2) Hypertension
3) Increased breath sounds
4) Decreased oxygen saturation

 

 

____    7.   Which description regarding the pathophysiology of persistent pulmonary hypertension should the nurse include in the teaching session with a newborn’s parents?

1) “Gas exchange occurs in the alveoli.”
2) “Oxygen is picked up, and carbon dioxide is released.”
3) “Blood is shunted away from the lungs, affecting oxygenation.”
4) “Blood flows from the right ventricle into the pulmonary artery.”

 

 

____    8.   Which nursing action is appropriate when providing care to a newborn who is experiencing cold stress?

1) Placing the baby in an open crib
2) Monitoring temperature every hour
3) Warming the formula prior to feedings
4) Avoiding skin-to-skin contact with the mother

 

 

____    9.   Which data cause the nurse to monitor a newborn’s blood glucose level?

1) Strong cry
2) Poor feeding
3) Hyperthermia
4) Hypertonicity

 

 

____  10.   Which intervention should the nurse include in the plan of care for a newborn experiencing hypoglycemia?

1) Maintaining an NPO status
2) Drawing a blood glucose level once per day
3) Making sure the baby is breastfed or bottle fed
4) Checking the blood glucose level 1 hour after feeding

 

 

____  11.   Which intervention should the nurse include in the plan of care for a newborn who is diagnosed with a brachial plexus injury?

1) Lifting the baby using the axillae
2) Allowing the affected arm to dangle
3) Monitoring for pain using an approved scale
4) Teaching the parents not to use a car seat because of the diagnosis

 

 

____  12.   Which intervention should the nurse include in the plan of care for a jaundiced newborn who is to receive phototherapy?

1) Keeping the baby fully clothed to avoid burns
2) Encouraging breastfeeding four to six times per day
3) Placing eye protection on the baby during therapy
4) Reporting fewer than two stools per day to the provider

 

 

____  13.   Which data will cause the nurse to monitor a newborn for sepsis?

1) Postterm delivery
2) Maternal respiratory infection
3) Frequent vaginal examinations during labor and delivery
4) Amniotic fluid ruptured for less than 24 hours during childbirth

 

 

____  14.   A septic newborn has been transferred to the Level III newborn intensive care unit (NICU) for treatment. Which statement regarding medical management should the nurse share with the newborn’s parents?

1) “We will be promoting thermoregulation in the NICU.”
2) “We will be monitoring your baby’s vital signs closely in the NICU.”
3) “We will be administering penicillin to treat your baby’s viral infection.”
4) “We will be placing a central line for the prescribed antibiotics in the NICU.”

 

 

____  15.   Which intervention should be included in the nursing plan of care for a newborn diagnosed with sepsis?

1) IV fluid
2) Placing a central line
3) Cardiopulmonary support
4) Promoting thermoregulation

 

 

____  16.   Which intervention should be included by the nurse in the plan of care for a family whose newborn is admitted to the NICU?

1) Referring to the baby using the last name
2) Allowing the parents to participate in the baby’s care
3) Withholding the baby’s true diagnosis until more family is present
4) Explaining to the parents that their baby cannot be held if intubated

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which clinical manifestations should the nurse anticipate in a newborn who develops respiratory distress within the first 8 hours of life? (Select all that apply.)

1) Dyspnea
2) Tachypnea
3) Hypothermia
4) Nasal flaring
5) Intercostal retractions

 

 

____  18.   Which nursing interventions are appropriate when providing care to a newborn who is experiencing cold stress? (Select all that apply.)

1) Assessing skin temperature
2) Monitoring respiratory status
3) Providing skin-to-skin contact
4) Infusing warmed IV fluids
5) Administering prescribed vasopressors

 

 

____  19.   Which clinical manifestations cause the nurse to report to the provider that a newborn is experiencing hypoglycemia? (Select all that apply.)

1) Hypotonia
2) Strong cry
3) Tachypnea
4) Poor feeding
5) Hypothermia

 

 

____  20.   Which interventions should the nurse include in the plan of care for a newborn diagnosed with hyperbilirubinemia who is receiving phototherapy? (Select all that apply.)

1) Monitoring for hypothermia
2) Placing patches to protect the retinas
3) Monitoring for lethargy and irritability
4) Weighing each diaper to determine stool output
5) Administering a prescribed exchange transfusion

 

Chapter 20: Introduction to Pediatric Nursing

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which term describes assisting a family to feel supported, listened to, and competent?

1) Enable
2) Empathy
3) Egocentric
4) Empowerment

 

 

____    2.   On which new morbidity topic should the pediatric nurse focus when providing health promotion to families?

1) Dietary fads
2) Unsafe neighborhoods
3) Cost of health insurance
4) Post-traumatic stress disorder

 

 

____    3.   Which initiative is the nurse following by not using the abbreviation QOD when documenting care that is provided every other day?

1) Read back verbal orders
2) Do Not Use Abbreviations
3) Handoff reports
4) Critical test results

 

 

____    4.   Which action should the nurse implement in order to apply the principles of family-centered care in the hospital environment?

1) Implementing strict visitation policy for siblings
2) Allowing a child to “cry it out” when parents leave the bedside
3) Encouraging parents to continue bedtime routines, such as reading a story
4) Discouraging cultural foods because they cannot be provided by the dietary department

 

 

____    5.   Which anatomical difference between adults and children places a pediatric patient at risk for insensible losses?

1) Large body surface area
2) Obligatory nose breathing
3) Disproportionate head size
4) Poorly developed intercostal chest muscles

 

 

____    6.   Which is the best method for providing orientation to a novice pediatric nurse to enhance communication skills when working with this population?

1) Real-time training
2) Simulation activities
3) Computer-based training
4) Written module instructions

 

 

____    7.   Which intervention is meant to enhance medication safety for inpatient pediatric units?

1) Computerized order entry
2) Hospital-based pharmacies
3) Double-checking drug orders with three nurses
4) Interaction with other nurses in the medication room

 

 

____    8.   For which stage of development must the nurse engage in total safety perception when providing patient care?

1) Toddler
2) Preschooler
3) Older infant
4) Younger infant

 

 

____    9.   Which toy should the nurse provide to the toddler-aged patient to promote development?

1) Music box
2) Board game
3) Pail and shovel
4) Large-piece puzzle

 

 

____  10.   Which toy should the nurse provide to the infant patient to promote development?

1) Music box
2) Board game
3) Pail and shovel
4) Large-piece puzzle

 

 

____  11.   Which toy should the nurse provide to the school-aged patient to promote development?

1) Music box
2) Board game
3) Pail and shovel
4) Large-piece puzzle

 

 

____  12.   Which toy should the nurse provide to the preschool-aged patient to promote development?

1) Music box
2) Board game
3) Pail and shovel
4) Large-piece puzzle

 

 

____  13.   Which pediatric anatomical factor increases the risk for respiratory failure when care is provided to a child?

1) Smaller airway
2) Obligatory nose breathing
3) Large posterior head bone occiput
4) Poorly developed intercostal chest muscles

 

 

____  14.   Which pediatric anatomical factor increases the risk for airway occlusion when care is provided to a child?

1) A large posterior head bone occiput
2) An increase in total body surface area
3) A decrease in circulatory blood volume
4) Intercostal chest muscles that are poorly developed

 

 

____  15.   Which nursing action supports the National Patient Safety Goals for 2016?

1) Securing oxygen and suction equipment at each bedside
2) Using two identifiers prior to medication administration
3) Teaching the pediatric patient how to use the call button
4) Ensuring the bed is left in the lowest position when leaving the room

 

 

____  16.   Which action enhances crib safety when providing care to a pediatric patient in the hospital setting?

1) Ensuring that all patients wear nonskid footwear
2) Keeping a name badge on the patient at all times
3) Storing items such as diapers and wipes at the bedside table
4) Allowing a toddler to sleep in an adult bed with side rails engaged

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which toddler characteristics require the nurse to implement enhanced safety precautions when providing care? (Select all that apply.)

1) Feeling invincible
2) Learning to crawl
3) Challenging limits
4) Desiring autonomy
5) Testing the environment

 

 

____  18.   Which infant characteristics require the nurse to implement enhanced safety precautions when providing care? (Select all that apply.)

1) Feeling invincible
2) Learning to crawl
3) Beginning to walk
4) Desiring autonomy
5) Testing the environment

 

 

____  19.   Which toys should the nurse include in the plan of care to promote age-appropriate development for the infant? (Select all that apply.)

1) Rattles
2) Music boxes
3) Picture books
4) Cubes for stacking
5) Multicolored mobiles

 

 

____  20.   Which toys should the nurse include in the plan of care to promote age-appropriate development for the toddler? (Select all that apply.)

1) Rattles
2) Music boxes
3) Picture books
4) Cubes for stacking
5) Black-and-white mobiles

 

Chapter 21: Health Promotion of the Infant: Birth to One Year

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which is an example of an anthropometric measurement the nurse documents for the infant in the medical record?

1) Heart rate
2) Pain rating
3) Blood pressure
4) Head circumference

 

 

____    2.   Which parental statement indicates the need for further education regarding newborn safety?

1) “I should lay my baby on his back when I put him to sleep.”
2) “It is important to support my baby’s head when I hold him.”
3) “My baby doesn’t require a hat unless I am wearing one also.”
4) “I shouldn’t overextend my baby’s shoulders when changing his clothing.”

 

 

____    3.   Which assessment data increase the risk for newborn airway compromise?

1) Long torso
2) Long neck
3) Large tongue
4) Large mandible

 

 

____    4.   Which statement regarding infant physical growth patterns should the nurse share with the parents of an infant?

1) “Your baby will double his birth weight by 3 months of age.”
2) “Your baby should double his birth weight by 9 months of age.”
3) “Your baby should triple his birth weight by 12 months of age.”
4) “Your baby will lose 15% of his body weight by 1 month of age.”

 

 

____    5.   At which age should the nurse suggest introducing rice cereal to the infant’s diet?

1) 3 months
2) 6 months
3) 9 months
4) 12 months

 

 

____    6.   Which parental statement about newborn and infant stooling patterns indicates the need for further education?

1) “A formula stool has a soft consistency.”
2) “A transitional stool is less thick and sticky.”
3) “A breastfed baby will stool only once per day.”
4) “A meconium stool is the first stool my baby will have.”

 

 

____    7.   Which parental statement regarding the sleep needs of a younger infant is accurate?

1) “My baby requires 22 to 23 hours of sleep each day.”
2) “My baby requires a 1- to 2-hour nap in the afternoon.”
3) “My baby requires a 1- to 2-hour nap in the morning.”
4) “My baby requires 16 hours of sleep each day, including two naps.”

 

 

____    8.   Which immunization should the nurse plan to give prior to newborn discharge from the hospital?

1) Rotavirus
2) Hepatitis B
3) Inactivated polio virus (IPV)
4) Measles, mumps, rubella (MMR)

 

 

____    9.   Which data cause the nurse to provide the parents of an infant with education regarding colic?

1) Abdominal pain accompanied by crying 3 days per week
2) No weight gain since the last well-child visit
3) Muscle mass that has decreased
4) Frequent emesis

 

 

____  10.   Which nursing action is appropriate when assessing an infant for respiratory distress?

1) Palpating for masses
2) Inspecting for head bobbing
3) Documenting the frequency of stools
4) Monitoring for visible loops of bowel

 

 

____  11.   Which data obtained during an infant’s health history interview cause the nurse to provide specific information about SIDS?

1) Sleeping on the back
2) Smoking in the home
3) Attending day care each day
4) Being behind on current vaccinations

 

 

____  12.   Which complementary therapy might the nurse encourage for an infant who is experiencing colic?

1) Herbal tea
2) Acupressure
3) Stone therapy
4) Massage therapy

 

 

____  13.   Which intervention should be included in the plan of care for an infant who is experiencing diaper rash?

1) Changing the diaper three times per day
2) Keeping the diaper area clean and dry
3) Using scented lotion on the diaper area
4) Applying nystatin cream four times per day

 

 

____  14.   Which data cause the nurse to report to the charge nurse that an infant is experiencing moderate dehydration?

1) A 5% weight loss
2) A 15% weight loss
3) A decrease in urine output
4) A delayed capillary refill time

 

 

____  15.   Which parental statement indicates understanding of methods to prevent newborn neurological injury?

1) “I should cover my baby’s head.”
2) “I should place my baby on her back to sleep.”
3) “I should never shake my baby, even if she won’t stop crying.”
4) “I should use the bulb syringe to remove secretions from my baby’s nose.”

 

 

____  16.   Which statement regarding plotting anthropometric measurements indicates correct parental understanding?

1) “Body mass index (BMI) is monitored closely during the first year of life.”
2) “Height, weight, and BMI are monitored from 3 to 18 years of age.”
3) “You will plot my baby’s weight, length, and head circumference through 4 years of age.”
4) “There are four charts used to monitor physical growth from birth to 18 years of age.”

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which nursing actions are included when collecting anthropometric measurements during the newborn assessment? (Select all that apply.)

1) Measuring head circumference
2) Monitoring blood pressure
3) Determining heart rate
4) Documenting length
5) Assessing weight

 

 

____  18.   Which immunizations should the nurse prepare the parents of an infant for during the 4-month well-child visit? (Select all that apply.)

1) Rotavirus
2) Hepatitis B
3) IPV
4) MMR
5) Diphtheria, tetanus, pertussis (DTP)

 

 

Completion

Complete each statement.

 

  1. The nurse is calculating the kilocalorie needs for a newborn aged 15 days of life. Which is the maximum number of kilocalories the newborn needs per day if the current weight is 4.5 kg? Record your answer as a whole number. ____________________

 

  1. What is the minimum overall fluid requirement, in milliliters, for a newborn who weighs 5 kg? Record your answer as a whole number. ____________________

 

Chapter 22: Health Promotion of the Toddler

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The parent of a toddler states, “My child is constantly saying ‘no.’” When documenting this in the medical record, which term should the nurse use?

1) Autonomy
2) Egocentric
3) Negativism
4) Temperament

 

 

____    2.   The parent of a toddler states, “My child wants to do everything by herself.” Which term should the nurse use to describe this behavior in the medical record?

1) Autonomy
2) Egocentric
3) Negativism
4) Temperament

 

 

____    3.   Which risk is increased for a child during the toddler stage of development because of exploration and curiosity?

1) SIDS
2) Suffocation injuries
3) Accidental poisoning
4) Motor vehicle accidents

 

 

____    4.   Which should the nurse recommend to the parents of a toddler who is exhibiting tantrums?

1) Ignoring the child’s behavior
2) Locking the child in the bedroom
3) Swatting the child on the backside
4) Giving in to the demands of the child

 

 

____    5.   Which is a priority teaching point regarding nutrition for the toddler-aged child?

1) Limiting milk consumption
2) Offering water with each meal
3) Offering the child finger foods only
4) Emphasizing the need for two snacks per day

 

 

____    6.   Which parental statement regarding the sleep needs of a toddler indicates the need for additional education from the nurse?

1) “My child should sleep a total of 14 hours per day.”
2) “My child will need only one afternoon nap versus two naps per day.”
3) “I should not put my child down for a nap too late in the afternoon.”
4) “I should expect my child to sleep 14 hours each night in addition to an afternoon nap.”

 

 

____    7.   Which activity should the nurse recommend to the parents of a toddler-aged child to challenge object permanence?

1) Jumping rope
2) Stacking blocks
3) Playing hide-and-go-seek
4) Reading books about colors

 

 

____    8.   Which should the nurse identify as most important to social development during the toddler stage of development?

1) Peers
2) Siblings
3) Religious figures
4) Day-care providers

 

 

____    9.   Which form of discipline should the nurse encourage when providing care to the family of a toddler-aged child?

1) Saying “no”
2) Ignoring the behavior
3) Implementing “time-outs”
4) Implementing corporal punishment

 

 

____  10.   The parents of a toddler have not sought the recommended dental care for their child. Which type of abuse should the nurse identify in this situation?

1) Physical abuse
2) Physical neglect
3) Emotional abuse
4) Emotional neglect

 

 

____  11.   Which data collected during the health history process cause the nurse to assess for autism?

1) Using pronouns incorrectly
2) Sleeping less than 14 hours per day
3) Using two-word sentences at 20 months of age
4) Lacking interest in games such as hide-and-go-seek

 

 

____  12.   The nurse is providing care to a toddler-aged client whose laboratory data indicate anemia. Which question should the nurse include in the health history of this patient?

1) “Does your child eat green leafy vegetables?”
2) “Does your child have a history of bleeding?”
3) “How much milk does your child drink each day?”
4) “Does your child eat the same types of foods as the rest of the family?”

 

 

____  13.   Which goal should the nurse include in the plan of care for a toddler-aged client who is diagnosed with seasonal flu?

1) “The child will verbalize the need to have a bowel movement.”
2) “The child will ask for fever reducers when hyperthermia occurs.”
3) “The child will sneeze and cough into a tissue provided by the caregiver.”
4) “The child will use hand sanitizer prior to touching other children in the day-care environment.”

 

 

____  14.   The home-care nurse is conducting a home visit for the family of a toddler-aged patient. Which finding necessitates education related to safety?

1) Drugs kept in a medicine cabinet in the bathroom
2) Knives stored on the counter out of reach
3) A bucket of water used for mopping in the hallway
4) Cleaning supplies stored in a locked cabinet under the sink

 

 

____  15.   Which point should the nurse include in a teaching session for the parents of a toddler-aged patient who live in a home with stairs?

1) Allowing the child to walk up and down the steps to enhance autonomy
2) Ensuring that the child is instructed not to use the steps without assistance
3) Placing a gate so the child is unable to access the steps without supervision
4) Suggesting that the family consider moving to a home that does not have steps

 

 

____  16.   Which nursing action is appropriate when assisting with the assessment of a toddler-aged patient who is diagnosed with a communicable disease?

1) Asking the parents if the child has been exposed to anyone who has been sick
2) Determining if the child has received the human papillomavirus (HPV) vaccine
3) Establishing if the mother was exposed to any sexually transmitted infections (STIs) during pregnancy
4) Monitoring for any musculoskeletal abnormalities

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which statements should the nurse include when discussing the use of child safety seats for the parents of a toddler-aged patient? (Select all that apply.)

1) “Your child should be placed in a safety seat that is rear facing.”
2) “If your child must be placed in the front seat, it is important to adjust the seat so it is as far from the dashboard as possible and to disengage the airbag system.”
3) “Your child can be secured using the seat belt provided within the vehicle without an additional car seat.”
4) “It is appropriate to hold your child in your lap for short distances if there isn’t room for a safety seat within the vehicle.”
5) “It is appropriate to place your child in the back seat with the use of an appropriate child safety seat.”

 

 

____  18.   Which push-pull toys should the nurse recommend for play when providing education to the parents of a toddler-aged patient? (Select all that apply.)

1) Child grocery carts
2) Large trucks or cars
3) Soft foam balls
4) Soft mats
5) Safety noodles

 

 

Completion

Complete each statement.

 

  1. The nurse is providing care to a toddler-aged patient who weighs 10 kg. What is the minimum number of kilocalories this child should receive each day? Record your answer as a whole number. ____________________

 

  1. The nurse is providing care to a toddler-aged patient who weighs 10 kg. What is the maximum number of kilocalories this child should receive each day? Record your answer as a whole number. ____________________

 

Chapter 23: Health Promotion of the Preschooler

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A pediatric nurse assesses the language skills of a preschool child. This nurse is assessing an aspect of which developmental domain?

1) Physical
2) Cognitive
3) Psychosocial
4) Moral/spiritual

 

 

____    2.   The mother of a 4-year-old male tells the clinic nurse that her son asked her about the differences in his anatomy and that of his baby sister. The nurse reassures the mother that this is normal behavior for her son because the child is in which of Freud’s developmental stages?

1) Oral stage
2) Anal stage
3) Phallic stage
4) Latency stage

 

 

____    3.   Which type of play should the nurse encourage when providing age-appropriate care to a preschool-aged child?

1) Team
2) Parallel
3) Solitary
4) Associative

 

 

____    4.   The nurse is conducting a health history for a preschool-aged patient. Which should the nurse anticipate regarding language development at the age of 4 years?

1) Using 50 words
2) Knowing 900 words
3) Answering simple questions with simple answers
4) Articulating complex and compound sentences

 

 

____    5.   According to Erikson, which should the nurse anticipate when assessing a preschool-aged child?

1) Being engaged in tasks
2) Questioning sexual identity
3) Having highly imaginative thoughts
4) Wanting to participate in organized activities

 

 

____    6.   Which result does the nurse anticipate when providing care to a preschool-aged child who successfully completes tasks associated with this stage of Erikson’s theory of psychosocial development?

1) Faith and optimism
2) Devotion and fidelity
3) Direction and purpose
4) Self-control and willpower

 

 

____    7.   The nurse is preparing to assess a preschool-aged child who states, “This is Bella, my bear. People tell me that they can’t hear Bella talking, but that hurts her feelings and makes her cry.” When documenting this interaction in the child’s medical record, which term should the nurse use?

1) Animism
2) Seriation
3) Conservation
4) Object permanence

 

 

____    8.   Which question allows the nurse to assess a preschool-aged child for delayed peer relationships?

1) “Can your child independently dress each day?”
2) “Does your child play with the other children in the playroom?”
3) “Has your child ever thought that asthma is a punishment?”
4) “Does your child become anxious before respiratory treatments?”

 

 

____    9.   Which activity should the nurse identify as a safety risk for a preschool-aged patient?

1) The parents are participating in a methadone program.
2) The parents consume alcohol on a daily basis.
3) The child watches television for 2 hours each day.
4) The child is permitted to swim in the family pool unsupervised.

 

 

____  10.   For which immunization booster does the nurse provide parental education during the health maintenance visit for a 4-year-old patient?

1) Hepatitis B
2) Haemophilus influenzae type B
3) Inactivated poliovirus (IPV)
4) Human papillomavirus (HPV)

 

 

____  11.   Which parental statement during a scheduled health maintenance assessment for a preschool-aged child causes the nurse concern?

1) “We have dinner together as a family each evening.”
2) “We are so proud that our child is able to recognize letters of the alphabet.”
3) “Our child wakes up each night screaming because of nightmares.”
4) “Our child attends a day-care program 3 days per week.”

 

 

____  12.   Which action should the nurse include when providing education regarding methods to enhance health promotion during a scheduled health maintenance visit for a 4-year-old child?

1) Recognizing that food jags are common
2) Mentioning the importance of foods high in sodium
3) Encouraging the use of a high chair with a safety strap
4) Recommending that the child consume high-fat foods

 

 

____  13.   The nurse is conducting a physical assessment for a preschool-aged child. When plotting the child’s body mass index (BMI), the nurse notes that the child is in the 90th percentile. Which action by the nurse is most appropriate?

1) Referring the child to a nutritionist
2) Conducting a developmental assessment
3) Assessing the child’s level of activity
4) Checking the child’s blood glucose level

 

 

____  14.   Which growth characteristic should the nurse anticipate when assisting with the physical examination process?

1) An increase in physical growth
2) The need for snacks due to blood glucose instability
3) The eruption of 15 of the 20 deciduous teeth
4) A weight gain of 5 lb per year

 

 

____  15.   The nurse is providing education to the parents of a preschool-aged child. Which statement regarding infectious disease should the nurse include in the teaching session?

1) “Immunizations are voluntary prior to entering the public school system.”
2) “Immunizations can increase the risk of your child developing ovarian cancer.”
3) “Immunizations decrease your child’s risk for developing autism spectrum disorder.”
4) “Immunizations can decrease the risk for serious complications associated with communicable diseases.”

 

 

____  16.   Which action is appropriate when assisting a preschool-aged child with hand washing?

1) Offering a hand towel to dry the hands
2) Using hot water to wash the hands
3) Singing the Happy Birthday song while washing the hands for timing purposes
4) Rinsing the hands, ensuring that the hands are upright

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which recommendations does the nurse make to the parents of a preschool-aged child who is experiencing frequent nightmares? (Select all that apply.)

1) Reassure the child by back rubbing
2) Repeat a nighttime routine, such as reading a story
3) Bring the child to the parental bed
4) Allow the child time to settle back into sleep
5) Place a television in the child’s room for distraction

 

 

____  18.   Which teaching points regarding pertussis should the nurse include in an educational session in the community? (Select all that apply.)

1) “This infection manifests on the scalp.”
2) “This infection will cause a scalelike rash.”
3) “This infection may cause the formation of scars.”
4) “This infection will cause violent coughing to occur.”
5) “This infection can be prevented through immunization.”

 

 

____  19.   Which statements should the nurse include in an educational session for a preschool-aged patient diagnosed with enuresis? (Select all that apply.)

1) “Bed-wetting might occur because of anxiety.”
2) “A diagnosis of enuresis occurs when bed-wetting occurs nightly.”
3) “Girls are more likely to experience bed-wetting than boys.”
4) “Bed-wetting can alter a child’s social experiences.”
5) “Nightmares are often associated with bed-wetting.”

 

 

____  20.   Which health screenings should the nurse include during a scheduled health maintenance visit for a preschool-aged patient? (Select all that apply.)

1) Vision
2) Obesity
3) Lead
4) Asthma
5) Platelets

 

Chapter 24: Health Promotion of the School-Aged Child

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse is teaching the parents of a 6-year-old child what to expect in terms of normal growth and development. Which parental statement indicates the need for further education?

1) “My child’s vision has reached maturity.”
2) “I should expect my child to be constantly active.”
3) “Finger feeding is abnormal and indicates the need for intervention.”
4) “A coloring book is a developmentally appropriate activity for my child.”

 

 

____    2.   Which physical change noted by the nurse during a growth and developmental assessment for a 7-year-old patient necessitates further action?

1) Pubescent changes
2) Weight gain of 4 lb (2 kg) per year
3) Eruption of central incisors
4) Height increase of 1 to 2 feet (30 to 60 cm) during the entire period

 

 

____    3.   Which should the nurse encourage for a school-aged patient to enhance a sense of accomplishment?

1) Wearing makeup
2) Going on a date
3) Participating in sports activities
4) Gaining weight during the school year

 

 

____    4.   The nurse is conducting a growth and development assessment and must calculate the body mass index (BMI) of a pediatric client. The child’s weight is 33 lb and 4 oz. The child’s height is 37 and 5/8 in. tall. What is the child’s BMI?

1) 14.5
2) 15.5
3) 16.5
4) 17.5

 

 

____    5.   Which stage of development is characterized by a slower, steadier pattern of growth and development?

1) Toddler
2) Preschool
3) School-age
4) Adolescence

 

 

____    6.   The mother of a school-aged patient says, “My daughter appears much thinner than she did a few years ago. Should I be worried?” Which response by the nurse is most appropriate?

1) “Does your child vomit after meals?”
2) “How many meals does your child eat each day?”
3) “It is important that we monitor your concern closely with frequent visits.”
4) “Body fat diminishes and distribution changes during this stage of development.”

 

 

____    7.   Which activity is easier for a school-aged child because of changes in proportions from the preschool stage of development?

1) Climbing
2) Handwriting
3) Problem-solving
4) Cooperative play

 

 

____    8.   Which psychosocial concern should the nurse monitor for when providing care to a school-aged child who is diagnosed with pediculosis?

1) Itching of the scalp
2) Feeling dirty
3) Applying medication appropriately
4) Educating the family on prevention

 

 

____    9.   Which growth and developmental change indicates increased maturity during the school-aged stage of development?

1) An increase in leg length in relation to height
2) A decreased head circumference in relation to standing height
3) The face growing faster in relation to the remainder of the cranium
4) Little increase in the size of the skull and the brain, which grow very slowly

 

 

____  10.   Which type of relationship is most important to the school-aged child?

1) Same-sex peer relationship
2) Opposite-sex peer relationship
3) Same-sex parental relationship
4) Opposite-sex parental relationship

 

 

____  11.   Which behavior noted by the school-aged patient indicates the development of conservation?

1) Learning to spell
2) Becoming interested in collections
3) Developing a sense of cause and effect
4) Being able to classify objects according to mass

 

 

____  12.   At which stage of development should the nurse anticipate that pediatric patients will begin to show differences in play activities that are related to gender?

1) Preschool
2) Adolescence
3) Late school age
4) Early school age

 

 

____  13.   Which teaching point regarding safety should the nurse include in instructions for the parents of a school-aged patient?

1) “Consider getting a pet for your child.”
2) “Plan play dates for your child to attend on afternoons you are not home.”
3) “Teach your children not to let others know that they are home alone after school.”
4) “Encourage your child to use a helmet when riding a bike. Other equipment is not necessary.”

 

 

____  14.   The nurse is providing care to a school-aged patient who is overweight. Which nursing action is appropriate to enhance the child’s intake of a healthy diet?

1) Offering food as a reward for good grades
2) Encouraging the consumption of high-fat foods
3) Educating on the importance of soda consumption
4) Making fruits and vegetables available for daily snacks

 

 

____  15.   How many hours of sleep should the nurse recommend for an 11-year-old patient?

1) 6 to 8
2) 8 to 10
3) 10 to 12
4) 14 to 16

 

 

____  16.   Which deciduous teeth should the nurse anticipate the school-aged child will lose first?

1) Lateral incisors
2) Central incisors
3) Third molars
4) Second molars

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   According to Piaget, which data does the nurse expect for a school-aged child during the nursing assessment process? (Select all that apply.)

1) Classifying objects
2) Understanding reversibility
3) Having theoretical thoughts
4) Describing a process without actually doing it
5) Believing personal actions are constantly being scrutinized

 

 

____  18.   According to Erikson, which should the nurse anticipate when assessing a school-aged child? (Select all that apply.)

1) Being engaged in tasks
2) Questioning sexual identity
3) Having highly imaginative thoughts
4) Wanting to participate in organized activities
5) Struggling with self-control and independence

 

 

____  19.   Which questions related to socialization should the nurse include when assisting with the assessment of a school-aged child who is new to the pediatric practice? (Select all that apply.)

1) “What grade are you currently attending?”
2) “At what age did your child cut the first tooth?”
3) “Do you have a best friend at your new school?”
4) “What was your child’s approximate length at 1 year of age?”
5) “What was your child’s approximate weight at 6 months and at 1, 2, and 5 years of age?”

 

 

____  20.   Which information related to school-aged play should the nurse include in a teaching session for the parents of children in this stage of development? (Select all that apply.)

1) Team play
2) Card games
3) Parallel play
4) Board games
5) Club membership

 

Chapter 25: Health Promotion of the Adolescent

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which is a theoretical reason for why adolescents engage in risky behavior?

1) As a coping mechanism
2) To impress a teacher
3) As a cry for help
4) To receive peer approval

 

 

____    2.   Which is often the reason why an adolescent engages in self-harm activities such as cutting?

1) For peer approval
2) For attention
3) To release anger
4) To seek medical attention

 

 

____    3.   According to Erikson, which person has the most influence over the adolescent?

1) Peers
2) Siblings
3) Parents
4) Teachers

 

 

____    4.   Which is a psychological and developmental task of adolescence?

1) Being engaged in tasks
2) Forming a self-identity
3) Having highly imaginative thoughts
4) Wanting to participate in organized activities

 

 

____    5.   The nurse is planning to teach a group of adolescents about what can happen during unprotected sex. Which nursing action allows effective communication with the group?

1) Offering personal opinions on the topic
2) Allowing for discussion among the participants
3) Lecturing on the topic for the allotted time without any discussion
4) Discussing sex education related to religious belief

 

 

____    6.   Which developmental theorist stated that the adolescent is able to logically manipulate abstract, observable, and nonobservable concepts with greater depth?

1) Erikson
2) Freud
3) Kohlberg
4) Piaget

 

 

____    7.   The nurse is assessing an adolescent patient to determine her relationships with others. Which nursing action is appropriate?

1) Telling the parents that information will be shared with them after the examination
2) Providing separate times to communicate with the adolescent and the parents
3) Avoiding asking the parents their opinions of the adolescent’s friends
4) Telling the parents they are not allowed to come into the examination room

 

 

____    8.   The nurse is planning care for an overweight adolescent. Which topic is appropriate to include in the plan of care?

1) Preventing substance abuse
2) Assessing for school phobia
3) Monitoring for spiritual distress
4) Determining self-esteem

 

 

____    9.   Which should the nurse keep in mind when providing care to an adolescent patient during the initial health maintenance visit at the provider’s office?

1) The importance of explaining procedures and introducing personnel to adolescents
2) Many adolescents are quiet and will offer no opinions.
3) The importance of attending to and discharging the adolescent quickly
4) Many adolescents are comfortable with their surroundings.

 

 

____  10.   Which nursing action is appropriate when providing care to an adolescent patient who is accompanied to an appointment by a parent?

1) Instructing the parent to stay in the waiting room, with the explanation that the adolescent will provide a report after the examination
2) Telling the parent it is against policy for a parent to accompany the adolescent to the examination room
3) Reassuring the parent that the nurse will discuss any parental concerns or questions after the examination
4) Allowing the parent to come into the examination room with the adolescent

 

 

____  11.   The school nurse is performing annual height and weight screenings. The nurse notes that three adolescent girls who are close friends have each lost 15 pounds over the past year. Which is the priority nursing action?

1) Obtaining a nutritional history for each of these adolescents
2) Referring these adolescents to the school psychologist
3) Calling the respective parents to discuss the eating pattern of each adolescent
4) Speaking with the adolescents in a group to discuss the problems associated with anorexia nervosa

 

 

____  12.   When planning community health promotion activities, which should the nurse consider when catering an educational session to the adolescent?

1) More females smoke cigarettes than males.
2) Marijuana is not an issue until college.
3) Alcohol and drug use often goes hand-in-hand with sexual intercourse.
4) There is no risk of texting and driving during adolescence.

 

 

____  13.   An obese adolescent who adamantly denies sexual activity has a positive pregnancy test. Which response by the nurse is most appropriate?

1) “When was your last menstrual period (LMP)?”
2) “Tell me how you feel about your body image.”
3) “Let’s discuss some activities that you have done within the past few months that could possibly lead to pregnancy.”
4) “Why are you denying sexual intercourse?”

 

 

____  14.   A mother reports that her adolescent daughter is always late. The mother states, “She was born late and has been late every day of her life.” Which response by the nurse is appropriate?

1) “Setting specific alarms and then reinforcing the value of being ‘on time’ may be helpful strategies.”
2) “Just let it go for now. Teachers and employers are the best people to help her be on time.”
3) “You need to establish specific time frames for your adolescent and be certain she adheres to them.”
4) “You have a major problem. There must be a lot of screaming in your home.”

 

 

____  15.   The parent of an adolescent states, “My daughter slouches all the time. She is so lazy.” Which should the nurse assess in order to provide the parent with the most appropriate anticipatory guidance?

1) Asthma
2) Depression
3) Alcohol use
4) Scoliosis

 

 

____  16.   During a health maintenance visit, an adolescent says, “I have no friends in my new school, and I no longer want to go to college. I know I will be lonely there, too.” Which priority screening should the nurse implement?

1) Substance abuse
2) Depression
3) Anorexia nervosa
4) Pregnancy

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which difficulties faced by an adolescent are attributed to normal development? (Select all that apply.)

1) Risk-taking
2) Rebelliousness
3) Peer socialization
4) Lack of cooperation
5) Hostility toward authority

 

 

____  18.   Which should be included in the anticipatory guidance for high-risk behaviors provided to adolescents and their parents during a health maintenance visit? (Select all that apply.)

1) Alcohol use
2) Tobacco use
3) Sexual preference
4) College application process
5) Motor vehicle accidents

 

 

____  19.   Which screenings are appropriate for an adolescent who admits to being sexually active during a scheduled health maintenance visit? (Select all that apply.)

1) Herpes simplex virus
2) Gonorrhea
3) Chlamydia
4) Impetigo
5) Mononucleosis

 

 

____  20.   Which topics are appropriate for the nurse to include in a teaching session for an adolescent patient who is experiencing acne? (Select all that apply.)

1) Discouraging the consumption of greasy foods
2) Washing the face twice per day
3) Using a mild soap on the face
4) Scrubbing the face with a washcloth
5) Recommending products that contain oil

 

Chapter 26: The Hospitalized Child

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The pediatric nurse is explaining the procedure for débriding a wound to a preschool-aged patient. Which is an age-appropriate method to describe this process?

1) Use play to demonstrate the procedure
2) Allow the child to see all of the equipment
3) Allow the child to refuse the procedure
4) Use pamphlets to describe the procedure

 

 

____    2.   The nurse prepares a child to receive oxygen via a tent delivery system by allowing the child to place a teddy bear in and out of the tent and then rewarding the child with a sticker. Which practice is the nurse using?

1) Therapeutic play
2) Therapeutic rewards
3) Therapeutic interventions
4) Therapeutic communication

 

 

____    3.   The nurse is providing care to a pediatric patient who is experiencing separation anxiety as a result of hospitalization. Which data indicate the patient is experiencing the “despair” stage?

1) Lies quietly in bed
2) Does not cry when parents return and leave again
3) Appears to be happy and content with staff
4) Screams and cries when parents leave

 

 

____    4.   Which is a common fear for hospitalized pediatric patients between the ages of 6 and 18 months?

1) Death
2) Disfigurement
3) Bodily mutilation
4) Stranger anxiety

 

 

____    5.   Which nursing action is most appropriate when providing emergency care to a child whose parents do not wish to leave the room?

1) Asking the health-care provider if the parents can stay with the child
2) Allowing the parents to stay with the child
3) Escorting the parents to the waiting room and assuring them that they can see their child soon
4) Telling the parents that they do not need to stay with the child

 

 

____    6.   Which pediatric patient is at greatest risk for experiencing separation anxiety if the parents are unable to stay with the child at all times?

1) A 3-month-old infant
2) An 18-month-old toddler
3) A 4-year-old, preschool-aged child
4) A 6-year-old, school-aged child

 

 

____    7.   A preschool-aged child is admitted to the pediatric unit for surgery. The parents request to stay with their child. Which is the best response by the nurse?

1) Tell the parents they can stay in the hospital but not on the unit
2) Read the rules and regulations of rooming in with the child
3) Let the parents know they are allowed to stay with the child
4) Explain to the parents why they cannot stay with the child

 

 

____    8.   Which tool should the nurse use to monitor pain in a toddler-aged patient?

1) FACES pain scale
2) FLACC pain scale
3) Oucher pain scale
4) Numeric pain scale

 

 

____    9.   Which nursing action is most appropriate to minimize stress for a pediatric patient who will have a planned hospitalization for a tonsillectomy and his or her family?

1) Telling the client and family that everything will be fine
2) Explaining to the client and family how the child will benefit from the surgery
3) Telling the client and family that the surgeon is very good
4) Giving the client and family a tour of the hospital unit or surgical area

 

 

____  10.   Which pediatric patient can best tolerate separation from parents during hospitalization?

1) A 3-month-old
2) A 15-month-old
3) A 24-month-old
4) A 36-month-old

 

 

____  11.   Which nursing action is most appropriate when updating the family of a preschool-aged patient?

1) Providing the update at the bedside
2) Giving the parents a written report from the providers
3) Stepping out of the room to discuss the information
4) Asking the provider to discuss all of the information with the family

 

 

____  12.   Which nursing action is most appropriate to reduce stress during the preoperative period for a 4-year-old patient?

1) Explaining to the child that the surgery will fix her “broken” heart
2) Waiting until the child is in the holding room to insert the Foley catheter
3) Telling the child what will be seen, heard, and felt while awake prior to the procedure
4) Asking the parents to wait in the waiting room when it is time to take the child to the holding area

 

 

____  13.   Which strategy is most appropriate for administering a medication to a toddler-aged child who has a history of being difficult?

1) Put the medication in a favorite drink in the child’s sippy cup
2) Notify the health-care provider to change the route to IV
3) Hold the child down and squirt the medication into the corner of his mouth
4) Allow the mother to administer the medication to the child

 

 

____  14.   Which action is most appropriate when providing care to a hospitalized pediatric patient who is on contact precautions because of a communicable disease?

1) Asking the parents to visit the child once per day
2) Scheduling physical therapy for the child
3) Providing age-appropriate stimulation for the child
4) Discouraging the parents from holding their child during the visit

 

 

____  15.   Which nursing action is appropriate for the parents of a hospitalized patient to enhance safety?

1) Allowing the parent to sleep in the bed with the patient
2) Keeping supplies on the bedside table to enhance their use
3) Teaching the use of the call bell system
4) Encouraging the child to walk barefoot to the bathroom

 

 

____  16.   For which topic, considered an adolescent stressor, should the nurse include interventions in the plan of care for a hospitalized teenage patient?

1) Fear of the dark
2) Separation anxiety
3) Mutilation concerns
4) Loss of privacy

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which nursing actions are appropriate when providing care to a toddler-aged patient who is restrained to protect an incision after a surgical procedure? (Select all that apply.)

1) Using the least restrictive method
2) Obtaining an order containing the reason, the type of restraint, and a start/stop time
3) Removing the restraints every 4 hours to assess skin
4) Encouraging games and activities that promote growth and development
5) Assessing hygiene and elimination needs frequently

 

 

____  18.   Which nursing actions are appropriate when providing care to a child who is hospitalized? (Select all that apply.)

1) Teaching the family that the doctor is the decision maker in the child’s care
2) Educating the family about procedures performed on the child
3) Providing emotional support to the child and the family
4) Administering age-appropriate care to the child
5) Communicating in a genuine fashion with the child’s family and health-care providers

 

 

____  19.   Which reactions should the nurse anticipate when providing care to a pediatric patient who is exhibiting the protest stage of separation anxiety? (Select all that apply.)

1) Clinging to the parents
2) Crying or acting aggressively
3) Withdrawing from the environment
4) Being disinterested when the family visits
5) Exhibiting depression

 

 

____  20.   Which nursing actions are appropriate when teaching a pediatric patient how to administer an insulin injection? (Select all that apply.)

1) Showing the child a syringe filled with water to practice on a favorite doll
2) Showing the child a video of another child receiving an insulin injection
3) Showing the child a picture of the beach to imagine jumping in the waves
4) Showing the child how the injection will occur by pretending to inject self
5) Showing the child how the injection occurs by allowing the child to watch another child receive the injection first

 

Chapter 27: Acutely Ill Children and Their Needs

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which is a responsibility of the nurse when implementing safety precautions for pediatric patients each shift?

1) Checking that the bedside equipment is functional and the right size
2) Verifying a dose of insulin with another nurse prior to administration
3) Using the 10 rights of medication administration with each drug given
4) Verifying the patient prior to administering a prescribed treatment

 

 

____    2.   Which nursing action exemplifies safe practice when providing care to pediatric patients?

1) Using therapeutic play for teaching
2) Allowing the parents to remain at the bedside as long as they wish
3) Implementing the rapid response team for a child who is experiencing complications
4) Scheduling a child life specialist for a patient who is on contact precautions

 

 

____    3.   Which action by the nurse is appropriate when using the “S” of the SBAR system?

1) Identifying the reason for the phone call
2) Giving the patient’s presenting complaint
3) Providing the most recent vital signs
4) Asking if the provider will be coming to assess the patient

 

 

____    4.   Which action by the nurse is appropriate when using the “A” of the SBAR system?

1) Identifying the reason for the phone call
2) Giving the patient’s presenting complaint
3) Providing the most recent vital signs
4) Asking if the provider will be coming to assess the patient

 

 

____    5.   Which action by the nurse is appropriate when using the “B” of the SBAR system?

1) Identifying the reason for the phone call
2) Giving the patient’s presenting complaint
3) Providing the most recent vital signs
4) Asking if the provider will be coming to assess the patient

 

 

____    6.   Which action by the nurse is appropriate when using the “R” of the SBAR system?

1) Identifying the reason for the phone call
2) Giving the patient’s presenting complaint
3) Providing the most recent vital signs
4) Asking if the provider will be coming to assess the patient

 

 

____    7.   Which code should the nurse call for a pediatric patient who is not breathing?

1) Code red
2) Code blue
3) Code pink
4) Code grey

 

 

____    8.   Which code should the nurse call for a fire in a patient care area?

1) Code red
2) Code blue
3) Code pink
4) Code grey

 

 

____    9.   Which code should the nurse call if a newborn is missing from the nursery?

1) Code red
2) Code blue
3) Code pink
4) Code grey

 

 

____  10.   The nurse witnesses a child collapsing in the cafeteria. Which is the priority action by the nurse?

1) Calling for help
2) Determining unresponsiveness
3) Performing chest compressions
4) Giving a resuscitative breath

 

 

____  11.   Which should the nurse monitor when assisting with the rapid assessment of body systems to assess a child’s cardiovascular system?

1) Presence of petechiae
2) Retinal hemorrhage
3) Paradoxical breathing
4) Abnormal heart sounds

 

 

____  12.   Which should the nurse monitor when assisting with the rapid assessment of body systems to assess a child’s integumentary system?

1) Presence of petechiae
2) Retinal hemorrhage
3) Paradoxical breathing
4) Abnormal heart sounds

 

 

____  13.   In which position should the nurse place a child who is experiencing a medical emergency in order to use color-coded resuscitative response tape?

1) Supine
2) Prone
3) Side-lying
4) Trendelenburg

 

 

____  14.   For which patient scenario should the nurse activate the rapid response team?

1) An infant who requires an IV catheter for antibiotic administration
2) A toddler-aged patient who is experiencing separation anxiety
3) A preschool-aged patient who requires a procedure with the implementation of restraints
4) A school-aged patient who has a grand mal seizure in the playroom

 

 

____  15.   Which guideline should the nurse include in the education provided to the parents of pediatric patients regarding the implementation of the rapid response team?

1) The team should be activated for customer service issues.
2) The team should be activated when an immediate care conference is required.
3) The team can be activated only by the family, but the nurse can assist with this process.
4) The team can be activated for signs and symptoms indicating the child is deteriorating, such as trouble breathing.

 

 

____  16.   Which nursing action exemplifies the therapeutic communication required when a child is moved to a higher level of care in an acute care facility?

1) Asking the provider on call to communicate why the child was transferred to intensive care
2) Calling the hospital social worker to communicate with the parents during the transfer process
3) Talking to the family in a calm, matter-of-fact manner, explaining each step of the transfer process
4) Instructing the family to go to the waiting room until a provider is available to update them on their child

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which information should the nurse include in the handoff communication with the receiving unit when a child is transferred to a higher level of care? (Select all that apply.)

1) The child’s nickname in order to enhance comfort when on the new unit
2) The date of admission and the diagnosis
3) A comprehensive history of the hospital stay up until the transfer
4) Any medical interventions that were attempted to stabilize the child prior to the transfer
5) The family members who are approved to receive information about the child via telephone

 

 

____  18.   Which nursing actions are appropriate when attempting to stabilize a pediatric patient who is experiencing shock? (Select all that apply.)

1) Placing the child in a prone position
2) Preparing for intubation and mechanical ventilation
3) Protecting the child’s vascular access line
4) Administering prescribed antianxiety medications
5) Using color-coded resuscitative tape to obtain accurate height and weight

 

 

____  19.   Which medications should the nurse be prepared to administer when providing care to a child who is experiencing shock? (Select all that apply.)

1) Cefazolin
2) Epinephrine
3) Insulin
4) Hydrocortisone
5) Diazepam

 

 

____  20.   Which should the nurse include when assessing the central nervous system (CNS) of a child who is acutely ill? (Select all that apply.)

1) Irritability
2) Lethargy
3) Hypoventilation
4) Vomiting
5) Seizures

 

Chapter 28: The Abused Child

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which health-care provider is mandated by law to report suspected child abuse?

1) Baptist priest
2) Day-care provider
3) Basketball coach
4) Registered nurse

 

 

____    2.   Which is the most common form of child abuse around the world that the nurse should assess for when caring for children?

1) Physical
2) Emotional
3) Neglect
4) Sexual

 

 

____    3.   Which child factor that contributes to abuse should the nurse assess for when abuse is suspected?

1) Low self-esteem
2) Temperament that is demanding
3) Stress that is chronic in nature
4) Poverty-level socioeconomic status

 

 

____    4.   Which clinical manifestation noted during a physical examination causes the nurse to suspect physical abuse?

1) Traumatic alopecia
2) Extremity fractures
3) Unilateral ecchymosis of the eye
4) Weight below the 10th percentile

 

 

____    5.   Which percentage of reported cases of child abuse in the United States reflects child neglect?

1) 12%
2) 16%
3) 24%
4) 52%

 

 

____    6.   Which environmental influence should the nurse include when assessing a child’s risk for abuse?

1) A history of cruelty to animals
2) A lack of follow-through for medical follow-up
3) The use of multiple health-care providers
4) The family frequently relocates to different geographical locations.

 

 

____    7.   Which is a child factor that may increase the risk for abuse?

1) Substance abuse
2) Lack of respite care
3) Developmental delay
4) History of divorce

 

 

____    8.   Which pediatric patient is at increased risk for child abuse, necessitating a focused nursing assessment?

1) A 3-year-old child who is toilet-trained
2) A 1-year-old child who was born at 41 weeks’ gestation
3) A 9-month-old child, born prematurely, who is diagnosed with reflux
4) A 10-year-old child who is active in sports and recently made the honor roll

 

 

____    9.   Which is a priority nursing action when providing care to a school-aged child who is experiencing abuse?

1) Meeting the child’s immediate psychological needs
2) Planning for the child’s long-term physical needs
3) Earning the trust of the child’s parents
4) Engaging the child in play to encourage expression of anxiety

 

 

____  10.   Which is a component of constructing patient-centered goals when planning care for a school-aged patient who is being abused?

1) Family-centered
2) Past-oriented
3) Measurable
4) Based on medical principles

 

 

____  11.   The nurse is providing care for a child of Asian descent who is experiencing an exacerbation of asthma. The nurse notes bruising on the child’s back in the shape of a Christmas tree. Which question exhibits therapeutic communication when conducting the health history assessment on the basis of the current data?

1) “Why are you subjecting your child to this treatment?”
2) “Do you use spooning when caring for your child’s breathing issues?”
3) “Have you ever been accused of abusing or neglecting your child?”
4) “Do you require a medical translator during the interview process?”

 

 

____  12.   The licensed practical nurse (LPN) notes annular ecchymosis on a school-aged child’s back. The LPN is not sure if this is due to abuse or a cultural practice. Which is the priority action by the LPN?

1) Contacting child protective services
2) Asking the registered nurse to assist with the assessment
3) Instructing the parent to proceed to the waiting room for the remainder of the examination
4) Initiating a child life specialist consult for a more in-depth assessment of the current situation

 

 

____  13.   The nurse suspects that a child is being sexually abused. Which nursing action is appropriate?

1) Using a personal cell phone to collect images for documentation
2) Asking a novice nurse to assist in the data collection
3) Reviewing institutional policy regarding reporting abuse to authorities
4) Bathing the child after the collection of evidence

 

 

____  14.   Which is a behavioral indicator of abuse when providing care to a pediatric patient?

1) Ecchymosis
2) Rash
3) Vaginal discharge
4) Radar gaze

 

 

____  15.   Which is a nursing responsibility when providing care to a child who is being abused?

1) Filing a report with child protective services
2) Taking photographs of the child’s injuries on a personal cell phone
3) Determining who is abusing the child
4) Washing a child who is being sexually abused upon arrival to the department

 

 

____  16.   Which circumstance requires the nurse to obtain assistance from local law enforcement when providing care to a child who is being abused?

1) For a child who is at risk for further abuse
2) For a child who is emotionally abused
3) For any child who is sexually abused
4) For any child who is physically neglected

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which are clinical manifestations of sexual abuse that the nurse should include when assisting with the assessment process? (Select all that apply.)

1) Radar gaze
2) Poor hygiene
3) Vaginal discharge
4) Positive chlamydia culture
5) Ecchymosis located on the inner thighs

 

 

____  18.   Which factors associated with sexual abuse should the nurse include in an educational session regarding this topic? (Select all that apply.)

1) Anyone can be an abuser.
2) The middle daughter is often the victim.
3) Male victims are less likely to report the abuse.
4) Pedophiles often choose to work closely with children.
5) The perpetrator is typically someone the family does not know.

 

 

____  19.   Which factors associated with Munchausen syndrome by proxy should the nurse include in an educational session regarding this topic? (Select all that apply.)

1) The child is usually under the age of 10 years.
2) The child often displays symptoms during the hospitalization.
3) The child has had multiple hospitalizations in the medical history.
4) The perpetrator is usually the father with some knowledge of health care.
5) The claimed history is not supported by evidence found by health-care providers.

 

 

____  20.   Which individuals are mandatory reporters of child abuse? (Select all that apply.)

1) Parents
2) Grandparents
3) Childcare providers
4) Commercial film developers
5) Child protective services employees

 

Chapter 29: Child With a Neurological Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which statement reflects appropriate understanding of the anatomy and physiology of the nervous system?

1) The brain is a network of nerve cells called axons.
2) The central nervous system consists of the brain only.
3) The peripheral nervous system consists of the cranial nerves and the spinal nerves.
4) Gray matter consists of axons that are coated with myelin, which allows nerve impulses to travel rapidly.

 

 

____    2.   Which item regulates emotions and behavior?

1) Thalamus
2) Brainstem
3) Spinal cord
4) Hypothalamus

 

 

____    3.   Which teaching point should be included in the plan of care for a toddler-aged patient to decrease the risk of traumatic brain injury (TBI)?

1) Using an appropriate rear-facing car seat
2) Using head support devices when placed in a car seat
3) Wearing a helmet when riding a tricycle
4) Teaching appropriate technique for diving

 

 

____    4.   For which pediatric patient should the nurse provide focused teaching regarding near drowning?

1) Toddler
2) Preschooler
3) School-aged
4) Early adolescent

 

 

____    5.   A child with a history of seizures arrives in the emergency department (ED) in status epilepticus. Which is the priority nursing action?

1) Taking vital signs
2) Maintaining a patent airway
3) Establishing an IV line
4) Performing rapid neurological assessment

 

 

____    6.   Which nursing action is appropriate when providing care to a toddler-aged patient whose lead level is 8 mcg/dL?

1) Conducting a survey of the environment
2) Following up as needed during future appointments
3) Administering prescribed edetate calcium-disodium (EDTA)
4) Preparing the patient for hospital admission for a full medical work-up

 

 

____    7.   Which action by the nurse is most appropriate for a child who presents with a history of migraine headaches?

1) Administering a prescribed opioid analgesic by intramuscular injection
2) Determining when the child’s last eye examination was conducted
3) Conducting a weight assessment and documenting the information in the medical record
4) Asking the parent if the child is experiencing night terrors

 

 

____    8.   Which assessment finding should the licensed practical nurse (LPN) report to the charge nurse when providing care to an infant with a ventral-peritoneal (VP) shunt?

1) Pupils equal and reactive to light
2) Apical pulse 110 beats per minute
3) Respiratory rate 32 breaths per minute
4) Tympanic temperature 102°F (38.8°C)

 

 

____    9.   The nurse is providing care to a school-aged child who was treated with aspirin during a viral infection. Which data should the LPN report to the charge nurse?

1) Eupnea
2) Lethargy
3) Urine output 30 mL/hr
4) Pupils equal and reactive to light

 

 

____  10.   A 9-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestation does the nurse expect to see in the baby?

1) Hypertonicity
2) Muscle dystrophy
3) Poor muscle coordination
4) Involuntary wormlike movements

 

 

____  11.   A pediatric patient is admitted to the ED with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed a heart rate of 48 bpm, a BP of 148/74 mm Hg, and a respiratory rate of 12 breaths per minute and irregular. Which does the nurse suspect?

1) Improvement
2) Typical for sleep
3) Spinal cord injury
4) Increased intracranial pressure

 

 

____  12.   Which nursing action is appropriate when assisting with the rapid assessment of a patient diagnosed with a neurological condition?

1) Assessing apical pulse
2) Monitoring blood pressure
3) Obtaining an oral temperature
4) Determining level of consciousness

 

 

____  13.   A teacher states to the school nurse, “I have a student who often just stares at me for 15 seconds after being asked a question; then the student blinks and asks me to repeat the question. Should I be concerned?” Which statement should the nurse include in the response to the teacher?

1) The child may have Reye’s syndrome.
2) The child may have had a head injury.
3) The child is experiencing absence seizures.
4) The child has increased ICP.

 

 

____  14.   Which preventive strategies should the nurse include in a teaching session for a mother whose infant is at risk for febrile seizures?

1) Decreasing oral fluid intake
2) Patting the child dry after a tepid bath
3) Administering dose-appropriate aspirin
4) Providing a sponge bath with cold water

 

 

____  15.   When care is provided to an infant, which clinical manifestation supports the diagnosis of meningitis?

1) Hypothermia
2) Soft, flat fontanel
3) Poor feeding habits
4) Cries that are consoled with holding

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  16.   The nurse is planning a teaching session for the parents of a child who has been diagnosed with simple partial seizures. Which characteristics of this type of seizure should the nurse include in the session? (Select all that apply.)

1) Lasts less than 30 seconds
2) Pain or numbness may occur.
3) Sudden stiffening followed by jerking
4) Chewing and lip smacking are common.
5) Remains conscious with no postictal period

 

 

____  17.   Which information should the nurse collect during the health history portion of the comprehensive neurological assessment for a pediatric patient? (Select all that apply.)

1) Accidents
2) Vital signs
3) Family history of seizures
4) Exposure to perinatal infection
5) Glasgow coma scale assessment

 

 

____  18.   Which nursing actions are appropriate to assist in the assessment of CN V? (Select all that apply.)

1) Asking the patient to smile
2) Asking the patient to identify different tastes
3) Asking the patient to follow finger commands with the eyes
4) Testing the patient’s response to cotton ball sensations on the face
5) Asking the patient to perform chewing movements on command

 

 

____  19.   Which information should the nurse elicit when collecting assessment data related to a child’s most recent seizure event? (Select all that apply.)

1) Precipitating events
2) Current medications
3) Any aura experienced
4) Description of movements
5) Family history of neurological disorders

 

 

____  20.   The parents of an infant visit the ED with complaints that their son is experiencing a high fever and lack of interest in breastfeeding. Upon examination, the nurse records the following symptoms of meningitis: nuchal rigidity, a bulging fontanel, and photophobia. Which tests does the nurse explain to the parents are necessary to confirm a diagnosis of meningitis? (Select all that apply.)

1) Kernig’s sign
2) Blood cultures
3) Rooting reflex
4) Lumbar puncture
5) Computed tomography scan

 

Chapter 30: Child With a Sensory Impairment

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which rationale for why young children are more prone to otitis media should the nurse include in the teaching session with a parent?

1) The eustachian tube is longer, wider, and vertical in younger children.
2) The eustachian tube is shorter, wider, and horizontal in younger children.
3) The eustachian tube is longer, more narrow, and vertical in younger children.
4) The eustachian tube is shorter, more narrow, and horizontal in younger children.

 

 

____    2.   Which neonate requires a close nursing assessment for the development of retinopathy of prematurity (ROP)?

1) A newborn of 28 weeks’ gestation who has been on long-term oxygen and weighed 1240 g at birth
2) A small-for-gestational-age newborn of 36 weeks’ gestation who was in an oxyhood for 12 hours and weighed 1800 g
3) A female newborn of 28 weeks’ gestation who was on short-term oxygen, weighed 1420 g, and was treated with phototherapy
4) A newborn of African heritage and 32 weeks’ gestation with a congenital heart defect who needed no oxygen and weighed 1850 g

 

 

____    3.   Which medication should the nurse plan to administer to decrease the risk of eye infection for a newborn?

1) Oral erythromycin
2) IV penicillin
3) Erythromycin eyedrops
4) Fluoroquinolone ointment

 

 

____    4.   Which nursing action is appropriate when teaching the family of a child diagnosed with bacterial conjunctivitis regarding medication administration?

1) Teaching that the drug should be administered one time per day
2) Encouraging the child to rub the eye after administration of the drug
3) Asking the child to hold the eye open when the drug is administered
4) Telling the child to lie down for 1 to 2 minutes after the drug is administered

 

 

____    5.   Which should the nurse include in the discharge instructions for the parents of an infant who is diagnosed with acute otitis media?

1) Administer a decongestant.
2) Place the baby to sleep with a bottle.
3) Keep the baby in a flat position during feedings.
4) Administer acetaminophen (Tylenol) to relieve discomfort.

 

 

____    6.   Which nursing action is appropriate when providing care to a child with mild hearing loss who reads lips in order to enhance adaptation during hospitalization?

1) Engaging the child with medical toys and dolls
2) Speaking directly to the parents for communication
3) Collecting only objective data during the health history
4) Providing only physiological support during the acute phase

 

 

____    7.   Which is the reason for a health-care provider recommending that a preschool-aged male client with documented hearing loss attend preschool at least 2 days per week?

1) To increase the child’s socialization skills
2) To help the child recognize his hearing deficit
3) To teach other children that children are different
4) To improve the child’s immunity by increased exposure to organisms

 

 

____    8.   Which tool should the nurse use to screen a pediatric patient for esotropia?

1) Perform the cover-uncover test
2) Examine the eye with an otoscope
3) Use a tonometer to evaluate the eyes
4) Check for the “red reflex” in the eyes

 

 

____    9.   Which information should the nurse include in order to prevent noise-induced hearing loss (NIHL) for pediatric patients?

1) Avoid the use of ear plugs
2) Participate in annual screenings
3) Stand close to amplifiers during live music
4) Use a cotton-tipped applicator for wax removal

 

 

____  10.   Which term should the nurse use when discussing a child with no sight sensory experience with other members of the health-care team?

1) Deaf
2) Blind
3) Hard of hearing
4) Visually impaired

 

 

____  11.   Which should the nurse include in the plan of care for a pediatric client diagnosed with otitis media with effusion?

1) Assessing for visual acuity
2) Assessing for speech delays
3) Administering prescribed aspirin for pain relief
4) Administering prescribed IV antibiotics

 

 

____  12.   Which term should the nurse use when discussing a child with a limited sensory experience for sight with other members of the health-care team?

1) Deaf
2) Blind
3) Hard of hearing
4) Visually impaired

 

 

____  13.   Which clinical manifestation causes the nurse to plan care based on a diagnosis of retinoblastoma for a pediatric patient?

1) Enucleation
2) Red reflex
3) Leukokoria
4) Cerumen buildup

 

 

____  14.   Which treatment should the nurse anticipate for a pediatric patient with an aggressive case of retinoblastoma?

1) Enucleation
2) Cryotherapy
3) Laser surgery
4) Cochlear implant

 

 

____  15.   Which may be a causative factor the nurse includes in a teaching session for a pediatric patient diagnosed with sensorineural hearing loss?

1) Otitis media
2) Foreign body
3) Cerumen buildup
4) Rubella syndrome

 

 

____  16.   Which reaction should the nurse anticipate when the family of an infant is told there is a sensory impairment?

1) Fear
2) Anger
3) Blame
4) Indifference

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which parental statements indicate correct understanding of the care that is needed for a pediatric patient after the insertion of tympanostomy tubes? (Select all that apply.)

1) “I should restrict my child to quiet activities after surgery.”
2) “It is important for my child to drink plenty of fluids after the procedure.”
3) “I will remind my child to use ear plugs prior to showering and swimming.”
4) “It is important to limit my child’s diet after surgery and allow only soft, bland foods.”
5) “I should plan to administer a decongestant to my child for 1 to 2 weeks following surgery.”

 

 

____  18.   Which topics should the nurse include in a teaching session for the parents of a 10-month-old infant who experiences frequent ear infections? (Select all that apply.)

1) Continuing to breastfeed
2) Avoiding use of woodburning stoves
3) Prohibiting tobacco smoke in the home
4) Cleaning the child’s ears nightly with peroxide
5) Avoiding use of a pacifier while the child is sleeping

 

 

____  19.   Which common eye disorders should the nurse include in a teaching session for the parents of pediatric clients? (Select all that apply.)

1) Myopia
2) Cataracts
3) Hyperopia
4) Strabismus
5) Astigmatism

 

 

____  20.   Which organizations should the nurse include in the teaching session for the parents of a child with a visual or hearing impairment? (Select all that apply.)

1) American Council of the Blind
2) National Federation of the Blind
3) American Academy of Pediatrics
4) National Association for Visually Handicapped
5) National Association for Parents of Children with Visual Impairments

 

Chapter 31: Child With a Mental Health Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which classification of medication should the nurse be prepared to teach the family of a child who is newly diagnosed with schizophrenia?

1) Opioid
2) Antianxiety
3) Neuroleptic
4) Antidepressant

 

 

____    2.   A school-aged child presents in the pediatric clinic with a parent who states, “My child complains of a stomachache almost every day before school.” Which mental health disorder should the nurse assess this child for on the basis of the current data?

1) Anxiety
2) Depression
3) Schizophrenia
4) Bipolar disorder

 

 

____    3.   A school-aged child presents with trouble concentrating at school along with trouble making decisions and recalling information. Which mental health disorder should the nurse assess this child for on the basis of the current data?

1) Anxiety
2) Depression
3) Schizophrenia
4) Bipolar disorder

 

 

____    4.   The nurse is providing care to an adolescent patient who is diagnosed with bipolar disorder. Which clinical manifestation noted by the nurse during the assessment process indicates the adolescent is currently experiencing mania?

1) Impulsive behavior
2) Feelings of emptiness
3) Increased need for sleep
4) Loss of interest in activities

 

 

____    5.   Which prescription should the nurse anticipate when providing care to an adolescent patient who is diagnosed with bipolar disorder?

1) Lithium
2) Valproate
3) Bupropion
4) Fluoxetine

 

 

____    6.   The nurse is providing care to an adolescent patient who is diagnosed with anorexia and is experiencing an imbalance of potassium. Which is the priority assessment for this patient?

1) Integumentary
2) Gastrointestinal
3) Cardiac function
4) Height and weight

 

 

____    7.   The nurse is providing care to a school-aged patient who is prescribed methylphenidate. Which clinical manifestation supports the use of the drug?

1) Talking excessively in class
2) Complaining of an upset stomach
3) Hearing and seeing things that are not there
4) Wanting to sleep more than 12 hours each day

 

 

____    8.   Which statement from the parents of a school-aged child diagnosed with ADHD indicates the need for further education by the nurse?

1) “I will develop a reward system for desired behaviors.”
2) “I will stick to the same routine each day after school.”
3) “I will let him do his homework while he is watching his favorite television show.”
4) “I will take my child to the physician every 3 months for a weight and height check.”

 

 

____    9.   A child diagnosed with autism spectrum disorder (ASD) is admitted to the hospital with dehydration. Which should the nurse include in the plan of care for this child?

1) Taking the child on a tour of the pediatric unit
2) Assigning the child to a single-bed hospital room
3) Taking the child to the playroom for arts and crafts
4) Discouraging the parents from bringing favorite toys from home that might be lost

 

 

____  10.   Which is an essential component when providing care to a pediatric patient who is experiencing an acute exacerbation of a mental health condition?

1) Establishing rapport
2) Collecting vital signs
3) Determining medication adherence
4) Documenting events leading to hospitalization

 

 

____  11.   Which information should the nurse include in the teaching plan for the parents of a child who is diagnosed with ASD as methods to increase the child’s socialization?

1) Create a reward system when the child interacts with a person.
2) Punish the child when the child’s social behaviors are inappropriate.
3) Use dolls to demonstrate appropriate social interactions to the child.
4) Enroll the child in a day-care facility to encourage interaction with other children.

 

 

____  12.   Which child should the nurse refer for further assessment because of a probable diagnosis of ASD?

1) A 6-year-old boy who chatters constantly to anyone who will listen
2) An 18-month-old child who walks around the area using the furniture to provide balance
3) A 4-year-old girl who doesn’t make eye contact with her mother and resists the mother’s touch
4) A 3-year-old boy who joins one group of children then moves to another group of children without joining their activities

 

 

____  13.   Which activity should the nurse include in the plan of care for a child diagnosed with ADHD to improve behavior and learning?

1) Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child
2) Placing the child’s desk at the back of the room to reduce distractions
3) Encouraging seasonal decorations in the classroom
4) Developing a consistent routine for the classroom

 

 

____  14.   The nurse is conducting a health history interview with the parents of a preschool-aged patient who believe the child may be suffering from depression. Which should the nurse monitor for during the assessment process?

1) Weight loss
2) Poor hygiene
3) Concentration
4) Decision making

 

 

____  15.   Which nursing action assists in the diagnosis of mental health and cognitive disorders that occur during childhood?

1) Monitoring vital signs
2) Administering prescribed medications
3) Conducting a developmental assessment
4) Documenting an accurate history and physical

 

 

____  16.   Which research topic is likely to have the most impact on the diagnosis and care a child receives regarding mental health issues?

1) Genetics
2) Medication
3) Risk factors
4) Development

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which clinical manifestations should the nurse monitor for when assisting in the assessment of a school-aged child who is the victim of bullying? (Select all that apply.)

1) Mania
2) Anxiety
3) Loneliness
4) Easily distracted
5) Suicidal thoughts

 

 

____  18.   Which behaviors exhibited by an adolescent who is diagnosed with depression cause the nurse to document that the patient is experiencing suicidal ideations? (Select all that apply.)

1) Suicidal thoughts but no plan
2) Suicidal thoughts with a plan
3) Surviving an intentional jump off a bridge
4) Collecting pills without a plan
5) Taking an intentional overdose of medication, resulting in death

 

 

____  19.   Which complications of substance abuse should the nurse monitor for when assisting with the assessment process for an adolescent? (Select all that apply.)

1) Autism
2) Violence
3) Alienation
4) Depression
5) Hopelessness

 

 

____  20.   Which categories of pharmacological treatment should the nurse be familiar with when providing care to children with a mental health diagnosis? (Select all that apply.)

1) Opioid
2) Antianxiety
3) Neuroleptic
4) Mood stabilizer
5) Antidepressant

 

 

 

 

Chapter 32: Child With a Respiratory Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which statement by the nurse accurately describes the difference between the respiratory systems of a child and an adult?

1) The nares in children are larger in size, shallow in depth, underdeveloped, and less easily occluded.
2) The larynx and the glottis are lower in the younger child’s neck, which makes the child more prone to aspiration.
3) The epiglottis in the younger child is longer and flaccid, making it more susceptible to swelling that may lead to airway occlusion.
4) There are fewer functional muscles in the neck, and the decreased amount of soft tissue makes the child more susceptible to infection and edema.

 

 

____    2.   A pediatric nurse is performing a respiratory assessment on an 18-month-old child. The nurse most likely uses which recommended techniques?

1) Assess breath sounds by listening to all lung fields and alternating sides for comparison
2) Assess the resonance of the lungs and underlying organs by using auscultation
3) Assess the child’s respiratory status when fully awake and active
4) Assess for normal breath sounds using palpation

 

 

____    3.   The pediatric nurse recognizes that normal breath sounds are equal bilaterally in intensity, rhythm, and pitch. Which respiratory sign may indicate that a child is hypoxic?

1) Stridor
2) Anxiety
3) Rhonchi
4) Crackles

 

 

____    4.   Which should the nurse anticipate when providing care to a child who aspirated a foreign body (FB)?

1) CT scan
2) Chest x-ray
3) Fluoroscopy
4) Bronchoscopy

 

 

____    5.   The nurse is providing care to an infant who is diagnosed as having Pseudomonas aeruginosa pneumonia. Which respiratory condition should the nurse suspect?

1) Cystic fibrosis
2) Choanal atresia
3) Bronchopulmonary dysplasia
4) Congenital diaphragmatic hernia

 

 

____    6.   Which information should the nurse include when teaching information regarding peak flow to a child diagnosed with severe asthma?

1) The test should be conducted at least once a week.
2) The yellow zone is considered the danger zone and indicates the need for immediate intervention.
3) The red zone is a caution zone indicating the need to slow down and have a rescue inhaler available.
4) The green zone indicates the child should continue to take prescribed medication and participate in normal activity.

 

 

____    7.   A pediatric nurse explains discharge instructions to the parents of a child who is postoperative from a tonsillectomy. Which instruction does the nurse stress?

1) Recommend vigorous toothbrushing.
2) Avoid highly seasoned and “sharp” foods.
3) Encourage coughing and clearing the throat.
4) Avoid popsicles the first day postoperative because of aspiration risk.

 

 

____    8.   The mother of a toddler-aged patient states, “My daughter seems to be at an increased risk for complications associated with respiratory infections.” Which response by the nurse is accurate?

1) “You are incorrect in your assessment.”
2) “Younger children do not breathe as deeply as do older children.”
3) “The younger child’s airway is smaller and more easily occluded.”
4) “Air passages are more likely to become blocked with mucus because younger children make more mucus than older children.”

 

 

____    9.   A toddler-aged patient presents to the emergency department with a sore throat and difficulty swallowing. The nurse suspects acute epiglottitis. Which nursing action is avoided on the basis of the current assessment data?

1) Vital signs
2) Throat culture
3) Medical history
4) Auscultation of breath sounds

 

 

____  10.   Which nursing action is appropriate for the parents of a 4-month-old infant who died as a result of sudden infant death syndrome (SIDS)?

1) Allowing the parents to hold, touch, and rock the infant
2) Advising the parents that an infant autopsy is not necessary
3) Interviewing the parents to determine the cause of the incident
4) Sheltering the parents from grief by not giving them any personal items of the infant, such as footprints

 

 

____  11.   Which parental statement at the conclusion of a teaching session regarding environmental controls for childhood asthma indicates correct understanding of the information presented?

1) “We’ll use pesticides to ensure that our home is free from pests.”
2) “We will replace the carpet in our child’s bedroom with tile.”
3) “We’re glad the dog can continue to sleep in our child’s room.”
4) “We’ll be sure to use the fireplace often to keep the house warm in the winter.”

 

 

____  12.   Which action should the nurse include in the plan of care for an infant who is diagnosed with acute respiratory distress?

1) Suctioning the airway
2) Placing in a prone position
3) Daily peak flow readings
4) Implementing breathing exercises

 

 

____  13.   Which independent nursing action is appropriate for a 2-month-old infant who is a direct admission to the pediatric unit with a diagnosis of ALTE?

1) Placing the child on contact isolation
2) Drawing blood for arterial blood gases
3) Placing the child on an apnea monitor
4) Placing the child on nasal cannula oxygen

 

 

____  14.   Which is the priority nursing action for a premature neonate who is experiencing intermittent apnea?

1) Calling a code blue
2) Administering oxygen
3) Performing back blows and chest thrusts
4) Providing stimulation by stroking the back

 

 

____  15.   Which question should the nurse include in the health history to determine the causative factor for the diagnosis of croup?

1) “Does your child have a history of asthma?”
2) “Has your child received the varicella vaccine?”
3) “Has your child recently been diagnosed with the flu?”
4) “Did your child recently receive an immunization for measles, mumps, and rubella?”

 

 

____  16.   On which patient at the greatest risk for croup should the nurse focus information regarding prevention?

1) A 3-year-old preschooler
2) A 6-year-old school-ager
3) A 10-year-old school-ager
4) A 13-year-old adolescent

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which data collected during the pediatric respiratory assessment require further action by the nurse? (Select all that apply.)

1) Stridor
2) Strong cry
3) Nasal flaring
4) Substernal retractions
5) Lung sounds clear to auscultation

 

 

____  18.   When assisting with the respiratory assessment of a pediatric patient, which should the nurse include to determine oxygenation? (Select all that apply.)

1) Skin
2) Sclera
3) Cornea
4) Nailbeds
5) Mucous membranes

 

 

____  19.   Which prescribed medications should the nurse educate the parents of a child with asthma to administer on a daily basis? (Select all that apply.)

1) Albuterol
2) Ipratropium
3) Theophylline
4) Racemic epinephrine
5) Leukotriene modifiers

 

 

____  20.   Which nursing actions are essential for safety when providing care to a pediatric patient at risk for respiratory compromise? (Select all that apply.)

1) Identifying distress
2) Documenting the care provided
3) Supporting a compromised airway
4) Keeping the parents abreast of changes
5) Choosing the appropriate method of oxygen

 

Chapter 33: Child With a Cardiac Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which statement accurately describes the structures of the heart?

1) The right atrium is a reservoir, or collecting chamber, for the peripheral venous return.
2) The left ventricle receives blood from the right atrium and pumps it into the lungs via the pulmonary artery.
3) The right ventricle receives blood from the left atrium and pumps it into the systemic circulation via the aorta.
4) The left atrium receives deoxygenated blood from the entire body (except the lungs) through the superior and inferior venae cavae with an approximate saturation of 100%.

 

 

____    2.   Which heart valve connects the right atrium to the right ventricle and is composed of “doors” that open to allow blood flow into the adjoining chamber and shut to prevent backflow?

1) Mitral valve
2) Aortic valve
3) Tricuspid valve
4) Pulmonary valve

 

 

____    3.   An infant with Down’s syndrome is diagnosed with a heart condition. The parents state, “The doctor says our baby has a large hole in the center of his heart.” Which congenital heart condition does the nurse suspect?

1) Pulmonary atresia
2) Pulmonic valve stenosis
3) Ventricular septal defect
4) Atrioventricular canal defect

 

 

____    4.   Which cardiac condition should the nurse suspect for a neonate who is experiencing a pressure gradient between the arms and legs when blood pressure is assessed?

1) Tricuspid atresia
2) Conal truncal defects
3) Coarctation of the aorta (CoA)
4) Transposition of the great arteries

 

 

____    5.   The nurse is providing care to an infant who presents with a fever, rash, and red eyes and lips, along with hand and feet edema. Which cardiac disease process does the nurse suspect?

1) Cardiomyopathy
2) Rheumatic fever
3) Kawasaki’s disease
4) Congestive heart failure

 

 

____    6.   The nurse is preparing a teaching session for an infant who is diagnosed with bradycardia. Which topic should the nurse review prior to conducting the session?

1) Atrial flutter
2) Atrial fibrillation
3) Junctional rhythms
4) Bundle branch block

 

 

____    7.   Which nursing action is appropriate when providing care to a school-aged patient who is scheduled for a cardiac catheterization?

1) Explaining to the parent that this noninvasive procedure has few risks
2) Monitoring vital signs pre- and postprocedure
3) Prescribing pain medication if tachycardia occurs
4) Monitoring temperature postprocedure only

 

 

____    8.   On the basis of cultural background, which reaction should the nurse anticipate when providing care to the family of a Hispanic newborn diagnosed with a congenital heart defect?

1) Refusing pain medication containing opioids
2) Initiating polite and modest interactions with providers
3) Believing that the baby’s condition is related to wrongdoing
4) Requesting extra time for rituals prior to medical procedures

 

 

____    9.   Which assessment finding indicates adequate peripheral perfusion for a child after a cardiac catheterization?

1) Capillary refill is greater than 3 seconds.
2) Sensation is decreased, with a weakened dorsalis pedis pulse.
3) Dorsalis pedis pulse is palpable, but posterior tibial pulse is weak.
4) Lower extremities are warm, with a capillary refill of less than 3 seconds.

 

 

____  10.   An infant who is diagnosed with a mild heart defect will not have surgical correction for at least 2 years. Which information should the nurse include in the discharge teaching regarding management in the home environment?

1) “Your child is not at risk for congestive heart failure.”
2) “It is important for your child to maintain normal activity.”
3) “It is important to avoid antipyretics for the treatment of fever.”
4) “Your child will have a low-grade fever until the defect is repaired.”

 

 

____  11.   A 2-month-old infant with a congenital heart defect is admitted to the pediatric intensive care unit with congestive heart failure (CHF). Which intervention should the nurse include in the infant’s plan of care?

1) Forcing fluids appropriate for age
2) Monitoring respirations during active periods
3) Giving larger feedings less often to conserve energy
4) Organizing activities to allow for uninterrupted sleep

 

 

____  12.   A toddler is prescribed digoxin (Lanoxin) for cardiac failure. Which should the nurse instruct the toddler’s parents to monitor for as a manifestation associated with digoxin toxicity?

1) Ataxia
2) Tinnitus
3) Bradycardia
4) Hypotension

 

 

____  13.   Which teaching point should the nurse include in the discharge instructions for a pediatric patient recovering from subacute bacterial endocarditis (SBE)?

1) Should not receive routine immunizations
2) Should be restricted from most play activities
3) Fever is expected for several weeks following infection.
4) Prophylactic antibiotics are required for any dental, oral, or upper respiratory tract procedures.

 

 

____  14.   Which parental statement regarding the use of Cyclosporin A after a heart transplant indicates correct understanding of the information presented by the nurse?

1) “This medication is used to treat infections.”
2) “This medication is used to prevent rejection.”
3) “This medication is used to treat hypertension.”
4) “This medication is used to reduce serum cholesterol level.”

 

 

____  15.   Which clinical manifestation does the nurse anticipate for a pediatric patient who is admitted with CHF?

1) Bradycardia
2) Tachycardia
3) Weight loss
4) Hypertension

 

 

____  16.   Which laboratory test does the nurse anticipate for a child who is admitted to the hospital with suspected rheumatic fever?

1) Throat culture
2) C-reactive protein
3) Antistreptolysin-O (ASO) titer
4) Erythrocyte sedimentation rate (ESR)

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which defects of the heart should the nurse include in the educational session for parents of a newborn diagnosed with tetralogy of Fallot? (Select all that apply.)

1) Overriding aorta
2) Ventral septal defect
3) Hypertrophic right ventricle
4) Pulmonary stenosis or atresia
5) Transposition of the great vessels

 

 

____  18.   Which nursing actions are appropriate when providing care to an infant diagnosed with tetralogy of Fallot who is having a “tet” spell? (Select all that apply.)

1) Administering oxygen
2) Drawing blood for a serum hemoglobin
3) Placing the child in knee-chest position
4) Administering diphenhydramine (Benadryl) as ordered
5) Administering IV morphine per prescriber’s order

 

 

____  19.   The nurse is teaching the parents of a 7-year-old child information related to appropriate heart rate and blood pressure readings for their child. Which information should the nurse include in the teaching session? (Select all that apply.)

1) Heart rate of 60 to 95 beats per minute
2) Heart rate of 65 to 110 beats per minute
3) Systolic pressure range of 100 to 120 mm Hg
4) Diastolic pressure range of 60 to 75 mm Hg
5) Blood pressure of 95 to 110/60 to 75 mm Hg

 

 

____  20.   Which clinical manifestations does the nurse anticipate for a pediatric client who is diagnosed with Kawasaki’s disease? (Select all that apply.)

1) Diarrhea
2) Joint pain
3) Thrombocytosis
4) Swollen lymph nodes
5) High fever for 1 day

 

Chapter 34: Child With a Metabolic Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which statement regarding the endocrine system is accurate?

1) The hypothalamus is a photosensitive gland that receives light through the optic nerve.
2) The pituitary gland produces two hormones called thyroxin and triiodothyronine.
3) The pancreas produces insulin and glucagon, which affect metabolism.
4) The adrenal glands produce steroidal sex hormones that regulate changes at puberty.

 

 

____    2.   Which clinical manifestation does the nurse anticipate when assisting with the assessment of a child diagnosed with acromegaly?

1) Weight loss
2) Hyperglycemia
3) Osteoarthritis
4) Dry skin

 

 

____    3.   Which should the nurse anticipate when providing care to a pediatric patient diagnosed with diabetes insipidus (DI)?

1) Anuria
2) Oliguria
3) Dependent edema
4) Uncontrolled diuresis

 

 

____    4.   Which is the priority nursing action when providing care for a school-aged child admitted to the hospital experiencing an adrenal crisis?

1) Administering prescribed fluids and electrolytes
2) Clustering care to enhance rest
3) Monitoring stool output
4) Providing pain relief and tepid baths

 

 

____    5.   The nurse is providing education to a school-aged child recently diagnosed with type 1 diabetes mellitus (DM). Which item will the nurse include in the teaching plan regarding sick day management?

1) Holding the prescribed dose of insulin
2) Monitoring blood glucose every 8 hours
3) Monitoring for ketones after each void
4) Encouraging exercise every 24 hours

 

 

____    6.   The nurse is providing care to a pediatric patient experiencing a hyperactive adrenal medulla. Which clinical manifestation should the nurse anticipate during the assessment process?

1) Hypoglycemia
2) Tachypnea
3) Constipation
4) Edema

 

 

____    7.   Which teaching point should the nurse include in the discharge instructions for the parents of an infant who has been diagnosed with congenital hypothyroidism and has been prescribed daily levothyroxine?

1) Stopping the medication as long as the child continues to grow
2) Preventing hypothermia with appropriate clothing
3) Changing formula because it is contraindicated with the prescribed medication
4) Monitoring growth and development without any other prescribed interventions

 

 

____    8.   Which prescriber prescription should the nurse anticipate when providing care to a pediatric patient diagnosed with SIADH?

1) Furosemide by mouth
2) Insulin injections as needed
3) Blood glucose monitoring as needed
4) Oral fluid restriction

 

 

____    9.   A 5-year-old child with a history of hypopituitarism presents with complaints of right hip and leg pain. Which prescribed medication for the diagnosis should the nurse identify as the cause for the current symptoms?

1) Daily growth hormone
2) Insulin before meals and bedtime
3) Desmopressin at bedtime
4) Cortisone injections

 

 

____  10.   Which clinical manifestations should the nurse anticipate when providing care to an adolescent client who presents with untreated Graves’ disease?

1) Hyperglycemia, ketonuria, and glucosuria
2) Weight gain, hirsutism, and muscle weakness
3) Tachycardia, fatigue, and heat intolerance
4) Dehydration, metabolic acidosis, and hypertension

 

 

____  11.   The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed because of a tumor. Which parental statement indicates the need for further education?

1) “I will call the doctor if my child has restlessness and confusion.”
2) “If my child has any gastric irritation, I will give him antacids.”
3) “If my child has vomiting and diarrhea, I will hold his hydrocortisone.”
4) “I will give my child his hydrocortisone in the morning.”

 

 

____  12.   An adolescent patient presents in the emergency department (ED) with confusion. The health-care provider suspects diabetic ketoacidosis (DKA). A STAT serum glucose is done, and the result is 715 mg/dL. Which clinical manifestations does the nurse anticipate upon assessment of this client?

1) Tachycardia, dehydration, and abdominal pain
2) Sweating, photophobia, and tremors
3) Dry mucous membranes, blurred vision, and weakness
4) Dry skin, shallow rapid breathing, and dehydration

 

 

____  13.   Which action related to insulin administration should the nurse include in the teaching plan for an adolescent client who has been newly diagnosed with DM, in order to avoid the development of lipoatrophy?

1) Rotating injection sites
2) Checking blood sugar levels at mealtime and bedtime
3) Using a sliding scale for additional coverage
4) Administering insulin via a pump

 

 

____  14.   Which sequela should the nurse include in the teaching session for a parent who does not believe in medication for the treatment of the newborn’s hypothyroidism?

1) Heart disease
2) Delayed mental processing
3) Renal failure
4) Thyroid storm

 

 

____  15.   Which assessment finding causes the nurse to question whether a preschool-aged boy diagnosed with phenylketonuria (PKU) shortly after birth is following the prescribed dietary restrictions?

1) The child’s body has a musty odor.
2) The child is a blue-eyed blond.
3) The child appears sleepy and uninterested in the surroundings.
4) The child has a sunburn over his entire body.

 

 

____  16.   Which type of nutrition should the nurse include when planning care for a newborn who is diagnosed with galactosemia?

1) Goat’s milk formula
2) Breast milk
3) Cow’s milk–based formula
4) Lactose-free formula

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   An endocrinologist orders a test(s) for a child to diagnose adrenal crisis. Which test(s) does the nurse anticipate on the basis of the child’s diagnosis? (Select all that apply.)

1) Computed tomography (CT) scan of the brain
2) White blood cell count
3) Chest radiography
4) Blood test to determine electrolyte levels
5) Aldosterone levels

 

 

____  18.   A mother brings her school-aged daughter to the pediatrician. Upon hearing the daughter’s symptoms, the health-care provider prescribes a test for type 1 DM. Which data collected during the nursing assessment support the diagnosis of type 1 diabetes? (Select all that apply.)

1) Polydipsia
2) Polyuria
3) Polyphagia
4) Enuresis
5) Hypoglycemia

 

 

____  19.   The nurse is providing information to an adolescent newly diagnosed with diabetes. Which clinical manifestations of DKA should the nurse include in the teaching session? (Select all that apply.)

1) Change in mental status
2) Tachycardia
3) Fruity breath odor
4) Rapid, shallow respirations
5) Abdominal pain

 

 

____  20.   Which assessment data for a pediatric client support the diagnosis of familial or idiopathic central DI? (Select all that apply.)

1) Polyuria
2) Polydipsia
3) Nocturia
4) Enuresis
5) Constipation

 

Chapter 35: Child With a Musculoskeletal Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which bone is a common location for musculoskeletal disorders during childhood?

1) Flat
2) Long
3) Short
4) Irregular

 

 

____    2.   To prevent rickets, which calcium requirement should the nurse include in a teaching session for the parents of a later school-aged child?

1) 500 mg
2) 800 mg
3) 1300 mg
4) 1500 mg

 

 

____    3.   Which imaging test should the nurse anticipate for a patient whose provider wants to visualize hard and soft tissue along with bone marrow, without the use of radiation?

1) Bone scan
2) Fluoroscopy
3) Computed tomography
4) Magnetic resonance imaging

 

 

____    4.   The nurse is assisting in the assessment process for a school-aged patient who reports groin pain all week. When assessing the right hip, the nurse finds that the hip does not fully rotate internally, and abduction is limited. On the basis of these data, which condition might the nurse suspect?

1) Osgood-Schlatter disease
2) Left hip and femur fracture
3) Legg-Calvé-Perthes disease
4) Slipped capital femoral epiphysis

 

 

____    5.   Which nursing action is appropriate when providing care for a child who is in a spica cast to decrease the risk for cast syndrome?

1) Discouraging frequent repositioning
2) Encouraging increased fluids and dietary fiber
3) Drying the cast using a hair dryer
4) Telling the parents the cast can be immersed in water

 

 

____    6.   Which parental statement indicates correct understanding regarding a type IV fracture of the femur?

1) “The break will not affect my child’s growth and long-term development.”
2) “The break requires open reduction and internal fixation.”
3) “The break results in premature closure of the epiphyseal plate.”
4) “The break will not impact my child’s circulation.”

 

 

____    7.   Which information should the nurse include in a teaching session for the parents of a child with a leg cast?

1) Apply warm compresses to the leg for the first 24 hours after the injury.
2) Provide a well-balanced diet consisting mostly of carbohydrates.
3) Elevate the casted extremity on pillows for at least the first 24 hours.
4) Apply cold packs to the leg 24 hours after the injury.

 

 

____    8.   Which data does the licensed practical nurse (LPN) report to the charge nurse for an infant suspected of having unilateral congenital hip dysplasia?

1) Lordosis
2) Trendelenburg sign
3) Telescoping of the affected limb
4) Asymmetry of the gluteal and thigh fat folds

 

 

____    9.   Which parental statement causes the nurse to include further education related to the care of a child who is diagnosed with congenital clubfoot?

1) “We’ll keep the casts dry.”
2) “We’re happy this is the only cast our baby will need.”
3) “We’re getting a special car seat to accommodate the casts.”
4) “We’ll watch for any swelling of the feet while the casts are on.”

 

 

____  10.   Which assessment finding requires an immediate nursing action when providing care to an adolescent who is postoperative for spinal fusion surgery?

1) Sleeps when not bothered but arouses easily with stimuli
2) Impaired color, sensitivity, and movement of lower extremities
3) Nausea relieved by antiemetics
4) Pain relieved by analgesics

 

 

____  11.   The nurse is providing care to a child who is diagnosed with Legg-Calvé-Perthes disease. Which parental statement regarding the child’s care indicates correct understanding of the information provided?

1) “We’re glad this will take only about 6 weeks to correct.”
2) “We understand adduction of the affected leg is important.”
3) “We know that surgical correction is the only medical intervention needed.”
4) “We will encourage our child to swim in the pool for exercise.”

 

 

____  12.   Which topic is the priority for the nurse who is teaching the family of an infant diagnosed with osteogenesis imperfecta?

1) Cast care
2) Traction care
3) Postoperative spinal surgery care
4) Trunk and extremity support during everyday care

 

 

____  13.   Which should the nurse include in a teaching session for the parents of an infant who will be placed in a Pavlik harness for the treatment of congenital developmental dysplasia?

1) Apply lotion or powder to minimize skin irritation.
2) Check at least two or three times a day for red areas under the straps.
3) Put clothing over the harness for maximum effectiveness of the device.
4) Place a diaper over the harness, preferably a thin, superabsorbent, disposable diaper.

 

 

____  14.   Which action by the nurse is appropriate for a child who presents in the emergency department with an ankle injury?

1) Avoiding compression of the area to allow tissue swelling as necessary
2) Performing passive range of motion (ROM) to the extremity
3) Lowering the extremity below the level of the heart
4) Applying ice to the extremity

 

 

____  15.   Which assessment finding for a toddler-aged child in balanced Bryant traction for a fractured right femur requires immediate action by the nurse?

1) The child keeps trying to turn and lie on his belly.
2) The ropes are unequal in length.
3) The child’s buttocks are resting on the bed.
4) The compression bandage wrapping the legs is wrinkled.

 

 

____  16.   Which data obtained by the nurse during the health history portion of the assessment process support the current diagnosis of Duchenne muscular dystrophy (MD) for an 18-month-old child?

1) The child was postmature by almost 2 weeks.
2) The child seems very muscular.
3) The child walked early and without support at 10 months.
4) The child’s older sister developed scoliosis in the fourth grade.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   The nurse performs a neuromuscular assessment of a child who is in Russell’s traction. Which assessment findings indicate the need for further intervention? (Select all that apply.)

1) A pain rating of 6 on an age-appropriate numeric pain rating scale
2) The child feels the distal part of the extremity when touched by the nurse.
3) The child does not have a significant amount of edema in the extremity.
4) The child has a capillary refill time of more than 3 seconds.
5) The child’s toes are cold and appear dusky.

 

 

____  18.   Which clinical manifestations should the nurse monitor for when conducting a scoliosis screening for a school-aged child? (Select all that apply.)

1) Lordosis
2) Prominent scapula
3) Pain
4) A one-sided rib hump
5) Uneven shoulders and hips

 

 

____  19.   Which clinical data noted by the nurse during the shift assessment indicate the pediatric client may be experiencing compartment syndrome? (Select all that apply.)

1) Pink, warm extremity
2) Dorsalis pedis pulse present
3) Prolonged capillary refill time
4) Pain not relieved by pain medication
5) Paresthesia of the leg

 

 

____  20.   Which interventions should the nurse include in the plan of care for an adolescent patient who is on complete bedrest after spinal fusion surgery secondary to scoliosis to prevent complications associated with immobility? (Select all that apply.)

1) Encouraging use of the spirometer every 2 hours while the patient is awake
2) Log rolling the patient every 2 hours while awake
3) Increasing intake of milk to maintain bone calcium
4) Increasing fruit and grains in the diet
5) Limiting fluid intake to reduce the need to void

 

Chapter 36: Child With a Gastrointestinal Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   A nurse educator teaches her students about the anatomy of the gastrointestinal system. Which description about the functions of these organs might be discussed?

1) Digestion begins in the lower portion of the gastrointestinal (ascending and descending colon) system.
2) The upper portion of the gastrointestinal system (mouth and esophagus) is responsible for nutrient intake or ingestion.
3) The small intestine transports food to the stomach by the process of peristalsis.
4) The large intestine does the main work of absorption through a system of villi and folds.

 

 

____    2.   The pediatric nurse understands how each developmental stage contributes to the promotion of the health of the child. Which is a normal developmental attribute of the digestive system of the infant?

1) The infant has a built-in safeguard to prevent choking while swallowing and sucking.
2) The passage from mouth to pharynx is larger to allow more liquid to be swallowed.
3) The infant’s stomach usually empties in 5 to 6 hours, necessitating frequent feedings.
4) The liver and pancreas are not mature until 12 months, which limits solid food intake.

 

 

____    3.   The pediatric nurse examines a 14-month-old patient for bowel sounds. Which assessment finding is typical for this stage of development?

1) Bowel sounds occur normally every 20 to 25 seconds.
2) Bruits are normally heard upon auscultation.
3) Hypoactive bowel sounds may indicate excessive activity is present.
4) Hyperactive bowel sounds mean rapid movement through the intestines.

 

 

____    4.   The pediatric nurse examines a 5-week-old infant who has been observed having projectile, nonbilious vomiting. Upon palpation, the nurse feels an olive-shaped mass in the midepigastrium. On the basis of these data, which condition does the nurse suspect?

1) Rectal atresia
2) Hypertrophic pyloric stenosis
3) Intussusception
4) Malrotation of the intestine

 

 

____    5.   An adolescent who is brought to the emergency department (ED) by his parents has the following symptoms: periumbilical pain that peaks at 4-hour intervals followed by right lower quadrant pain, which is followed by vomiting. On the basis of these data, which condition does the nurse suspect?

1) Meckel’s diverticulum
2) Omphalitis
3) Appendicitis
4) Ulcerative colitis

 

 

____    6.   A pediatric nurse examines the abdomen of a preschool-aged child brought to the doctor’s office by the grandmother because of vomiting over the last several days. Upon inspection, the nurse observes that the child’s stomach is distended. On the basis of these data, which condition does the nurse suspect?

1) Intestinal obstruction
2) Kidney failure
3) Displaced abdominal organs
4) Omphalitis

 

 

____    7.   A pediatric nurse discusses with the parents medications prescribed for a school-aged child who is diagnosed with Crohn’s disease. Which are usual pharmacological options for treatment?

1) Antidiarrheal drugs
2) Antianxiety drugs
3) Diuretic drugs
4) Cardiac drugs

 

 

____    8.   The pediatric nurse is interpreting laboratory values for a patient suspected of having ulcerative colitis. Which finding does the nurse anticipate on the basis of the diagnosis?

1) Microcytic anemia
2) Decreased sedimentation rate
3) Decreased white blood cell count
4) Protein in the urine

 

 

____    9.   The nurse is preparing to discharge a child diagnosed with Hirschsprung’s disease from the hospital. Which topic is appropriate for the nurse to include in the discharge teaching with the child’s parents?

1) The foods to avoid because of increased risk for allergic reactions
2) The importance of eliminating dairy products
3) The care required for a temporary colostomy
4) Home administration of total parental nutrition (TPN) and lipids

 

 

____  10.   The nurse is providing care to a pediatric client diagnosed with inflammatory bowel disease who is prescribed daily prednisone. Which parental statement regarding administration of this drug indicates correct understanding of the teaching provided by the nurse?

1) “I will administer this medication between meals.”
2) “I will administer this medication at bedtime.”
3) “I will administer this medication 1 hour before meals.”
4) “I will administer this medication with meals.”

 

 

____  11.   Which assessment data cause the nurse to suspect that a 3-year-old child has Hirschsprung’s disease?

1) Clay-colored stools and dark urine
2) History of early passage of meconium in the newborn period
3) History of chronic, progressive constipation and failure to gain weight
4) Continual bouts of foul-smelling diarrhea

 

 

____  12.   An adolescent client reports recurrent abdominal pain with diarrhea and bloody stools. Which type of inflammatory bowel disease does the nurse suspect on the basis of these data?

1) Necrotizing enterocolitis (NEC)
2) Ulcerative colitis (UC)
3) Crohn’s disease
4) Appendicitis

 

 

____  13.   The nurse is assessing abdominal girth for a pediatric client who presents with vomiting. Which nursing action is appropriate?

1) Measuring the girth just below the umbilicus
2) Measuring the girth just below the sternum
3) Measuring the girth just above the pubic bone
4) Measuring the girth around the portion of the stomach

 

 

____  14.   A newborn diagnosed with an omphalocele defect is admitted to the intensive care nursery. Which nursing action is appropriate on the basis of the current data?

1) Placing the newborn on a radiant warmer
2) Placing the newborn in an open crib
3) Preparing the newborn for phototherapy
4) Preparing the newborn for a bottle feeding

 

 

____  15.   Which parental statement at the end of a teaching session by the nurse indicates correct understanding of colostomy stoma care for the infant client?

1) “We will change the colostomy bag with each wet diaper.”
2) “We will expect a moderate amount of bleeding after cleansing the area around the stoma.”
3) “We will watch for skin irritation around the stoma.”
4) “We will use adhesive enhancers when we change the bag.”

 

 

____  16.   Which parental action observed during a home-care visit for an infant diagnosed with gastroesophageal reflux requires intervention by the nurse?

1) The infant’s formula has rice cereal added.
2) The mother holds the infant in a high Fowler position while feeding.
3) After feeding, the infant is placed in a car seat.
4) The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   A neonate is born with a bilateral cleft lip that was not detected during the pregnancy. The parents are distressed about the appearance of their infant. Which nursing actions are appropriate to assist the parents in bonding with their newborn? (Select all that apply.)

1) Calling the newborn by the chosen name
2) Keeping the newborn’s lower face covered with a blanket
3) Smiling and talking to the newborn in the parents’ presence
4) Showing the parents before and after pictures of other children with cleft lips
5) Discussing positive features of the baby

 

 

____  18.   Which statements made by the adolescent following dietary teaching for Crohn’s disease indicate correct understanding of the content presented by the nurse? (Select all that apply.)

1) “I can promote solid stools by increasing fiber in my diet.”
2) “Small, frequent meals are preferred over three meals a day.”
3) “I should identify foods that cause distress and eliminate them from my diet.”
4) “High-calorie dietary supplement shakes can help me meet my nutritional requirements.”
5) “Socialization during mealtime is important even if my parents do not agree with my food choices.”

 

 

____  19.   Which gastrointestinal defects often diagnosed shortly after birth should the nurse include in the assessment process of all newborns? (Select all that apply.)

1) Pyloric stenosis
2) Biliary atresia
3) Hirschsprung’s disease
4) Crohn’s disease
5) Cleft palate

 

 

____  20.   The nurse is providing care to a newborn client who presents in the pediatric clinic for a 2-week health maintenance visit. The parents of the newborn are concerned because their baby has “gas all the time.” Which responses from the nurse are appropriate? (Select all that apply.)

1) “Your baby has a relaxed lower esophageal sphincter, which is causing the gas.”
2) “Your baby lacks the enzyme amylase, which is causing the gas.”
3) “Your baby lacks the enzyme insulin, which is causing the gas.”
4) “Your baby has an immature liver, which is causing the gas.”
5) “Your baby lacks an enzyme that helps to digest fats, which is causing the gas.”

 

Chapter 37: Child With a Genitourinary Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   The nurse educator teaches a group of nursing students about the anatomy and physiology of the kidneys. Which statement made by a student indicates an appropriate understanding of the information presented?

1) “The medulla is composed of the glomeruli and convoluted tubules of the nephron and blood vessels, which filter the urine.”
2) “The blood supply of the kidney is through a single renal artery that comes from each side of the aorta, one to each kidney.”
3) “Blood flows into the glomerulus through the efferent arteriole and leaves through the afferent arteriole.”
4) “The tubular components of the nephron are divided into four parts; the first part is a coiled portion termed the loop of Henle.”

 

 

____    2.   A school-aged child is diagnosed with pyelonephritis. When planning to teach the child’s parents about this diagnosis, the nurse tells them that the infection is located in which structure?

1) Bladder
2) Renal pelvis
3) Renal parenchyma
4) Reproductive tract

 

 

____    3.   Which data collected by the nurse support the diagnosis of isotonic dehydration for a pediatric patient?

1) Emesis
2) Hemorrhage
3) Profuse sweating
4) Poor fluid intake

 

 

____    4.   The nurse is performing a physical assessment of a school-aged child with a history of urinary tract infection (UTI). The child’s urine has been brownish lately. On the basis of these data, the nurse explains that a diagnostic test may be ordered to assess for which item in the urine?

1) Ketones
2) Hematuria
3) Proteinuria
4) Calcium

 

 

____    5.   An adolescent is brought to the emergency department. The patient reports decreased urine output, headaches, and abdominal swelling. On the basis of these data, which condition does the nurse suspect?

1) Chronic glomerulonephritis
2) Vesicoureteral reflux
3) Acute hematuria
4) Unexplained proteinuria

 

 

____    6.   The nurse is caring for an infant who is diagnosed with a UTI. Which symptom does the nurse anticipate when assessing this infant?

1) Dysuria
2) Poor feeding
3) Flank pain
4) Enuresis

 

 

____    7.   Which is the appropriate nursing intervention when providing care to a child diagnosed with nephrotic syndrome who is edematous and on bedrest?

1) Monitoring blood pressure every 30 minutes
2) Repositioning every 2 hours
3) Limiting visitors
4) Encouraging fluids

 

 

____    8.   Which urinalysis result should the nurse anticipate for a child who is admitted with acute glomerulonephritis?

1) Bacteriuria and increased specific gravity
2) Hematuria and proteinuria
3) Proteinuria and decreased specific gravity
4) Bacteriuria and hematuria

 

 

____    9.   Which laboratory test should the nurse prepare to draw when admitting a pediatric patient with possible obstructive uropathy?

1) Platelet count
2) Blood urea nitrogen (BUN)
3) Partial thromboplastin time (PTT)
4) Blood culture

 

 

____  10.   Which clinical manifestations should the nurse anticipate upon assessment of a preschool-aged child with a UTI?

1) Headache, hematuria, and vertigo
2) Foul-smelling urine, elevated blood pressure (BP), and hematuria
3) Urgency, dysuria, and fever
4) Severe flank pain, nausea, and headache

 

 

____  11.   The nurse is providing care to a 4-year-old patient who is experiencing nocturnal incontinence. Which parental statement indicates the need for further education?

1) “Bed-wetting is typically self-limiting.”
2) “We should limit fluids after lunchtime.”
3) “We should not punish our child for bed-wetting.”
4) “Bed-wetting can be treated with a drug that reduces urine production at night.”

 

 

____  12.   Which menu choices for a child diagnosed with urinary disorder leading to hyperkalemia indicate the need for further instruction by the nurse?

1) Carrots and green, leafy vegetables
2) Spaghetti and meat sauce with breadsticks
3) Hamburger on a bun and cherry gelatin
4) Chips, cold cuts, and canned foods

 

 

____  13.   Which congenital anomaly should the nurse document when providing care to a newborn with abnormal positioning of the urinary meatus?

1) Hydrocele
2) Micropenis
3) Hypospadias
4) Cryptorchidism

 

 

____  14.   Which type of urine specimen is collected when the nurse places a cotton ball in the diaper of a newborn or infant?

1) Sterile
2) Uro bag
3) Clean catch
4) Midstream sample

 

 

____  15.   Which is the priority nursing intervention when caring for a neonate who is born with bladder exstrophy?

1) Measuring intake and output
2) Inserting a Foley catheter
3) Covering the defect with sterile plastic wrap
4) Palpating the bladder mass to ensure urine is expelled

 

 

____  16.   Which is the correct hourly rate of IV fluid replacement for a child who weighs 25 kg?

1) 42 mL/hr
2) 63 mL/hr
3) 67 mL/hr
4) 83 mL/hr

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   The nurse educator is teaching a group of students about the risk factors for UTIs. Which risk factors stated by the students indicate an appropriate understanding of the information presented? (Select all that apply.)

1) Urinary stasis
2) Obstruction
3) Unexplained proteinuria
4) Reflux
5) Unexplained hematuria

 

 

____  18.   An adolescent patient presents to the emergency department with acute scrotal pain. After the initial assessment, the nurse suspects testicular torsion. Which assessment data support this diagnosis? (Select all that apply.)

1) The torsed testicle may be lower in the scrotal sack than the opposite testicle.
2) The situation is bilateral.
3) The testicle may feel hard.
4) Prehn’s sign is usually absent in torsion.
5) Temperature of 101.8°F

 

 

____  19.   Which clinical manifestations assessed when performing a genitourinary assessment for a child diagnosed with hemolytic uremic syndrome could indicate the need for dialysis? (Select all that apply.)

1) Edema
2) Tachypnea
3) Bradycardia
4) Fluid retention
5) High BP

 

 

____  20.   Which instructions should be provided to the parents of a 4-year-old girl who has experienced chronic UTIs in the last 2 years? (Select all that apply.)

1) Wear only nylon underwear for better airflow.
2) Teach the child to wipe from front to back.
3) Encourage the child to take long baths by allowing the child bubbles and toys in the tub.
4) Encourage the child to drink additional fluids throughout the day.
5) Plan potty breaks every 2 hours throughout the day.

 

Chapter 38: Child With a Skin Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which parental statement regarding preventive strategies for insect bites and stings indicates the need for further education?

1) “If my child wears bright colors and floral prints when outdoors, she will blend in with the surroundings, and the stinging insects will not sting her.”
2) “We should remove any items with standing water from our yard and surrounding area to prevent mosquito reproduction.”
3) “My child can use insect repellent containing DEET of 10% or less.”
4) “My child should avoid heavy colognes, perfumes, and soaps so that insects are not attracted to them.”

 

 

____    2.   The pediatric nurse is assessing a wound on a preschool-aged child’s leg and notes that the site is pink with the formation of new epithelial cells. Based on these data, which term does the nurse use to describe the current stage of healing?

1) Proliferation
2) Inflammation
3) Restoration
4) Remodeling

 

 

____    3.   The nurse is providing care to a child diagnosed with impetigo. The child’s parents ask what caused this to occur. Which organism does the nurse include when educating the parents about impetigo?

1) Staphylococcus aureus
2) Human papillomavirus (HPV)
3) Pseudomonas aeruginosa
4) Escherichia coli

 

 

____    4.   Which is the priority nursing intervention for a 4-year-old patient brought to the emergency department (ED) for treatment of frostbite?

1) Administering analgesics
2) Immersing the hands in extremely warm water (48.9°C [120°F])
3) Not removing clothing
4) Placing the extremity in a dependent position

 

 

____    5.   During the assessment of a child, the nurse notices the presence of vesicles that are oozing yellow fluid. Which term does the nurse use when documenting this finding in the medical record?

1) Bulla
2) Pustule
3) Wheal
4) Nodule

 

 

____    6.   The pediatric nurse is providing a preschool-aged child’s mother with information regarding impetigo. The mother is concerned about the possibility of passing the infection on to her other toddler-aged child. Which response by the nurse is most appropriate in this situation?

1) “I know that you are concerned about the health of both of your children. Your child has been prescribed 7 days of antibiotic therapy. After 24 hours of antibiotic therapy, you will not need to worry about any transmission of bacteria to your other child.”
2) “Caring for both of your children right now will take more time than usual. Do you have anyone who can come and help you with their care?”
3) “To decrease the chance of exposing your younger child, both children must have all of their linens, towels, and toys washed to prevent the spread of disease. In addition, it is best to wash everyone’s hands well.”
4) “You need to concern yourself only with the child who has impetigo. It is important to ensure that all of the medication is taken and that all toys and linens are washed in the next 24 hours.”

 

 

____    7.   The nurse is teaching the parents of an infant diagnosed with candidiasis in the diaper area how to treat this occurrence and decrease the risk for future occurrences. Which teaching point does the nurse include in the teaching session?

1) Finishing all of the antiviral medication as prescribed
2) Keeping the diaper area as dry as possible
3) Changing to a lactose-free formula
4) Administering an oral antifungal liquid for prevention of future occurrences

 

 

____    8.   Which is the most likely cause for a bright red perianal inflammation with scaly plaques and small papules noted by the nurse during the assessment of a 12-month-old infant?

1) Candida albicans (yeast)
2) Impetigo (Staphylococcus)
3) Infrequent diapering
4) Urine and feces

 

 

____    9.   Which finding noted by the school nurse while conducting pediculosis capitis (head lice) checks indicates the need for treatment?

1) White, flaky particles throughout the scalp region
2) Lesions on the scalp that extend to the hairline or neck
3) Maculopapular lesions behind the ears
4) Silver/white sacs attached to the hair shafts in the occipital area

 

 

____  10.   A 10-year-old child is admitted to the hospital following an accident at school that resulted in a puncture wound of the abdomen. Two days after the injury, the child continues in the inflammation phase of healing. What does the nurse expect to see while changing the child’s dressing and assessing the wound?

1) The wound is contracting, and the edges are growing together.
2) A blood clot has formed, sealing the wound.
3) Epithelial cells are growing into the wound.
4) The wound is pale and weepy.

 

 

____  11.   Which is the priority intervention when planning care for an infant who is diagnosed with eczema?

1) Applying antibiotics to lesions
2) Keeping the baby content
3) Maintaining adequate nutrition
4) Preventing infection of lesions

 

 

____  12.   Which parental statement indicates to the nurse an accurate understanding regarding the care of a child with tinea capitis (ringworm of the scalp)?

1) “We will give the griseofulvin with milk or peanut butter.”
2) “We’re glad ringworm isn’t transmitted from person to person.”
3) “Once the lesion is gone, we can stop the griseofulvin.”
4) “Well, at least we don’t have to worry about the family cat getting ringworm.”

 

 

____  13.   Which nursing action is accurate when applying a 5% permethrin lotion to a toddler with scabies?

1) Applying the lotion to the scalp, the forehead, and everywhere below the chin
2) Applying the lotion only to areas with evidence of activity
3) Applying the lotion only to the hands
4) Applying the lotion only to the scalp

 

 

____  14.   Which should the nurse include in the plan of care for a child with a minor burn to enhance nutrition and healing?

1) Protein
2) Minerals
3) Carbohydrates
4) Fats

 

 

____  15.   A toddler pulled a pot of boiling water off the stove and suffered partial and full-thickness burns to the chest. The child is now in the recovery-management phase of burn treatment. Which common complication should the nurse assess this client for on the basis of the current data?

1) Asphyxia
2) Metabolic acidosis
3) Shock
4) Wound infection

 

 

____  16.   The nurse explains to the parents of a child with a severe burn that wearing an elastic pressure garment (Jobst stocking) during the rehabilitative stage can help prevent which complication?

1) Pain
2) Hypertrophic scarring
3) Poor circulation
4) Formation of a thrombus in the burn area

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   Which skin conditions should the nurse identify as having a genetic or inherited component during a presentation to the staff nurses who work in the integument clinic? (Select all that apply.)

1) Atopic dermatitis
2) Seborrheic dermatitis
3) Epidermolysis bullosa
4) Molluscum contagiosum
5) Psoriasis

 

 

____  18.   Which preventive strategies for tinea pedis, a fungal infection also known as athlete’s foot, should the nurse include in a teaching session for an adolescent client? (Select all that apply.)

1) Wear white, 100%-cotton socks, changed twice a day.
2) Use talc on the feet daily.
3) Use an over-the-counter corticosteroid cream to treat the area.
4) Wear foot covers such as flip-flops in the locker room and shower.
5) Apply heat to the area twice a day.

 

 

____  19.   Which adolescent statements indicate the need for further education related to the prevention and treatment of acne? (Select all that apply.)

1) “I should wash my face each day with an approved cleanser.”
2) “I should wash my hands frequently and avoid touching my face.”
3) “I should stay away from greasy foods such as pizza.”
4) “I should shampoo my hair only once per week.”
5) “I should use my topical medication only when acne is present.”

 

 

____  20.   Which topics should be included in a teaching session with parents of school-aged children to prevent sunburn? (Select all that apply.)

1) Playing in the shade
2) Wearing a hat while outdoors
3) Restricting outside activities between 10 a.m. and 2 p.m.
4) Using sunscreen with an SPF of 30 or higher
5) Avoiding sunglasses

 

Chapter 39: Child With a Communicable Disease

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   When evaluating a pediatric patient’s laboratory data, the nurse knows that which blood cell component seeks out and destroys organisms that might cause disease?

1) Antibodies
2) T lymphocytes
3) Antigens
4) Neutrophils

 

 

____    2.   When conducting a child’s physical assessment, the pediatric nurse recognizes that the child’s “slapped cheek” facial rash is associated with which virus?

1) Epstein-Barr
2) Fifth disease
3) Varicella-zoster
4) Hepatitis A

 

 

____    3.   The pediatric nurse concludes parent teaching about children and influenza by asking: “How long does the incubation period for influenza last?” Which response by the parent indicates appropriate understanding?

1) 3 to 6 days
2) 1 to 2 days
3) 1 to 3 days
4) 4 to 6 days

 

 

____    4.   A 4-month-old infant is brought to the clinic to have a second diphtheria, tetanus, and pertussis (DTaP) vaccine. The infant’s mother states that the infant has had a runny nose for the last 2 days but no fever. Prior to administering the infant’s immunization, which question from the nurse to the mother is the most appropriate?

1) “Weren’t you aware that your baby can’t get immunizations when experiencing a runny nose?”
2) “Did your baby have any reaction following the first DTaP?”
3) “Did you bring your baby’s immunization record with you today?”
4) “Did you remember to premedicate your infant with steroids?”

 

 

____    5.   An adolescent patient has blood drawn by the clinic nurse for laboratory studies confirming an infection with the Epstein-Barr virus. The clinic nurse is teaching the adolescent and parents about the appropriate treatment. Along with rest and acetaminophen (Tylenol) for pharyngitis, which other point does the nurse include in the educational session?

1) Tepid baths three times a day
2) Oral care and the use of mouthwash
3) An extended absence from contact sports
4) Frequent follow-up clinic appointments

 

 

____    6.   A new mother brings her infant to the clinic for a 1-month checkup. The mother confides that she has heard many concerns expressed by other parents about immunizations and is not sure that she wants her baby to receive any immunizations. Which response by the nurse is the most appropriate?

1) “Please write down all of your questions for the doctor.”
2) “I can provide you with Web sites where you can get further information.”
3) “Receiving advice from others can be challenging. Can you tell me your concerns?”
4) “We can talk about this further at your next appointment.”

 

 

____    7.   Which personal protective equipment (PPE) should the nurse don when providing care within 3 feet of a pediatric patient who is on droplet precautions?

1) Gown
2) Gloves
3) Mask
4) Eye shield

 

 

____    8.   The nurse is teaching parents how to prevent the spread of infectious disease. Which priority health promotion strategy should the nurse recommend for all age groups of children?

1) Decreasing environmental exposure to pathogens
2) Performing hand hygiene
3) Ensuring all toys are clean and free from germs
4) Keeping children away from sick adults

 

 

____    9.   A child who has not had a tetanus immunization steps on a rusty nail. Which term should the nurse use to identify the tetanus immunization when teaching the parents about the vaccine?

1) Toxoid
2) Live virus
3) Killed virus
4) Recombinant

 

 

____  10.   Which nursing action is appropriate when providing care to a pediatric patient who is on expanded contact precautions?

1) Using soap and water for hand hygiene
2) Wearing a mask when within 3 feet of the patient
3) Wearing shoe protection
4) Using alcohol-based sanitizer for hand hygiene

 

 

____  11.   A mother refuses to have her child immunized with the measles, mumps, and rubella (MMR) vaccine because she believes that letting her infant get these diseases will help him fight off other diseases later in life. Which is an appropriate response by the nurse?

1) Telling the mother that by not immunizing the child, she may be exposing pregnant women to the virus, which could cause fetal harm
2) Honoring the mother’s request because she is the parent
3) Telling the mother that she is wrong and should have her child immunized
4) Explaining the potential complications of measles, mumps, and rubella infections

 

 

____  12.   A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate on the basis of the current data?

1) Withholding the DTaP vaccination but giving the others as scheduled
2) Giving the infant the flu vaccination but withholding the others
3) Giving the vaccinations as scheduled
4) Withholding the vaccinations

 

 

____  13.   A parent reports that her 5-year-old child, who has had all the recommended immunizations, had a mild fever 1 week ago and now has bright red cheeks and a lacy red maculopapular rash on the trunk and arms. Which diagnosis does the nurse anticipate on the basis of the current data?

1) Rubeola (measles)
2) German measles (rubella)
3) Chickenpox (varicella)
4) Fifth disease (erythema infectiosum)

 

 

____  14.   The nurse is providing care to a child who is diagnosed with Lyme disease. The mother wants to know how to protect her other children from contracting this disease from the infected child. Which should the nurse include in the teaching session regarding the transmission of this disease process?

1) Person to person
2) Animal to person
3) Adult to child
4) Person to insects

 

 

____  15.   Which is the priority nursing action when it is suspected that an infectious agent has been used as a weapon by terrorists?

1) Separating patients according to age
2) Initiating airborne and contact precautions
3) Separating patients according to level of development
4) Disposing of blood-contaminated needles in a lead-lined container

 

 

____  16.   Which nursing action is most appropriate to decrease the risk of transmitting viral infections by patients and family members at a local clinic?

1) Sanitizing toys, telephones, and doorknobs to kill pathogens
2) Teaching parents safe food preparation and storage
3) Withholding immunizations for children with compromised immune systems
4) Allowing all children to congregate in the same waiting room

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   A child presents in the emergency department (ED) after experiencing flu-like symptoms for 24 hours. The health-care provider diagnoses the child with swine influenza. Which assessment data collected by the nurse support this diagnosis? (Select all that apply.)

1) Fever
2) Skin lesions
3) Malaise
4) Red rash on the face
5) Rhinorrhea

 

 

____  18.   The mother of an immunocompromised child expresses concern that her child will “catch” a disease from the scheduled vaccination. Which vaccines can be administered to this child because they carry no risk for acquiring the infection? (Select all that apply.)

1) Toxoid
2) Killed virus vaccine
3) Live virus vaccine
4) Attenuated vaccine
5) Immunoglobulins

 

 

____  19.   Which nursing actions allow a child to acquire active immunity against a disease? (Select all that apply.)

1) Administering a dose of immunoglobulins
2) Administering a killed virus vaccine
3) Administering a toxoid vaccine
4) Administering antibiotic therapy
5) Administering antiviral therapy

 

 

____  20.   There has been an outbreak of communicable diseases in the community. To reduce parental anxiety, the nurse presents information about diseases at the school’s Parent Teacher Association meeting. Which vector-borne diseases, not communicable from person to person, should the nurse include in the teaching session? (Select all that apply.)

1) Measles
2) Whooping cough
3) Rocky Mountain spotted fever
4) West Nile virus
5) Lyme disease

 

Chapter 40: Child With an Oncological or Hematological Condition

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____    1.   Which primary function of red blood cells (RBCs) should the nurse consider when providing care to a pediatric patient who has been diagnosed with anemia?

1) Mediating the immune system to decrease areas of serious inflammation
2) Transporting hemoglobin that carries oxygen from the lungs to the tissues
3) Migrating and providing a rapid defense against any foreign agent
4) Providing hemostasis and vascular repair following injury to a vessel wall

 

 

____    2.   The pediatric nurse teaches the parents of a preschool-aged child diagnosed with anemia that it is important to identify the cause of anemia so treatment can be tailored to their child’s specific needs. The nurse tells the parents that their child’s anemia is caused by an increased destruction of red blood cells that occurs with which condition noted in the medical history?

1) Bone marrow failure
2) Acute blood loss
3) Myelodysplastic syndrome
4) Sickle cell anemia

 

 

____    3.   A hematologist diagnoses a school-aged child with thrombocytopenia. When educating the parents of the child about this condition, which description of the disease does the nurse include?

1) A decrease in platelets
2) An increase in red blood cells
3) A decrease in white blood cells
4) An increase in platelets

 

 

____    4.   Which parental statement indicates correct understanding of information presented regarding the treatment for infant anemia?

1) “We will add green leafy vegetables to our child’s low-iron formula.”
2) “We will discontinue the use of vitamin C supplements by 6 months of age.”
3) “We will begin an iron-fortified infant cereal at 4 to 6 months of age.”
4) “We will introduce cow’s milk by 6 months of age.”

 

 

____    5.   The pediatric nurse plans care for a child experiencing a sickle cell crisis. Which nursing intervention is appropriate for this patient?

1) Encouraging an increased amount of activity
2) Monitoring respiratory status and oxygenation
3) Using only nonpharmacological pain interventions to avoid an acute pulmonary event
4) Implementing fluid restrictions

 

 

____    6.   When talking to the parents of a school-aged cancer patient, the pediatric nurse identifies which as the most common cancer found in children?

1) Nasopharyngeal cancer
2) Acute lymphocytic leukemia
3) Chronic lymphocytic leukemia
4) Ewing sarcoma

 

 

____    7.   The pediatric nurse explains to a parent that his child’s sarcoma arises from which type of tissue?

1) Connective
2) Epithelial
3) Lymphatic
4) Glandular

 

 

____    8.   On the basis of a child’s complaint of abdominal pain, the nurse suspects a Wilms’ tumor. An abdominal mass associated with a Wilms’ tumor will be detected in which location?

1) On one side
2) On the front side
3) On both the left and right sides
4) On all sides of the abdomen

 

 

____    9.   A school-aged child is tentatively diagnosed with acute lymphocytic leukemia. The clinic nurse reviews the child’s laboratory results and recognizes that which finding reflects the best prognosis?

1) WBC count greater than 30,000/mm3
2) WBC count greater than 20,000/mm3
3) WBC count less than 10,000/mm3
4) WBC count less than 5000/mm3

 

 

____  10.   The parents of an infant diagnosed with sickle cell disease ask, “How did our child get this disease? Neither one of us has it.” Which should the nurse consider when responding to the parents?

1) The child is adopted.
2) The mother of the child has the trait, but the father does not.
3) The father of the child has the trait, but the mother does not.
4) The mother and the father of the child have the sickle cell trait.

 

 

____  11.   The nurse is administering packed red blood cells to a child with sickle-cell disease (SCD). When should the nurse monitor the child closely because of the risk of reaction?

1) 6 hours after the transfusion is given
2) At the end of the administration of the transfusion
3) The first 20 mL of blood administered
4) Never; children with SCD do not have reactions

 

 

____  12.   A child diagnosed with aplastic anemia is admitted to the hospital. The parents ask the nurse what aplastic anemia is. Which response by the nurse is accurate?

1) “Aplastic anemia causes a proliferation of white blood cells.”
2) “Aplastic anemia is characterized by abnormally shaped red blood cells
3) “Aplastic anemia is caused by the bone marrow producing inadequate cells.”
4) “Aplastic anemia is a disorder that occurs after a viral illness.”

 

 

____  13.   Which nursing action is appropriate when treating a school-aged child diagnosed with hemophilia for a superficial wound above the knee?

1) Applying pressure to the area
2) Applying a warm, moist pack to the area
3) Performing some passive range of motion to the affected leg
4) Keeping the affected extremity in a dependent position

 

 

____  14.   Which is the priority teaching point for the nurse to include in the discharge instructions for the parents of a child who was admitted in a sickle cell crisis?

1) Rapid weaning of pain medications
2) A diet high in protein
3) Adequate hydration
4) Restriction of activities

 

 

____  15.   The nurse is preparing to administer a blood transfusion to a child with severe anemia. Which type of transfusion reaction can be avoided by the nurse’s assessment?

1) Allergic
2) Hemolytic
3) Febrile
4) Septic

 

 

____  16.   Which is the priority nursing intervention for a pediatric client diagnosed with leukemia who has a granulocyte count of 250/mm3 and a platelet count of 150,000/mm3?

1) Fluid restriction
2) Mouth care
3) Neutropenic precautions
4) Hand hygiene

 

 

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

 

____  17.   A school-aged African American male is brought to an emergency department (ED) by his parents with a vaso-occlusive crisis. When caring for this child, the nurse monitors for which conditions during the assessment? (Select all that apply.)

1) Uncontrolled bleeding
2) Acute chest syndrome
3) Splenic sequestration
4) Leg ulcerations
5) Diuresis

 

 

____  18.   The clinic nurse conducts an interview with an adolescent diagnosed with beta-thalassemia and his parents. Prior to planning the adolescent’s care, which should the nurse take into consideration? (Select all that apply.)

1) There is no cure for beta-thalassemia, but early remission is possible.
2) Hemosiderosis may occur as a result of chronic blood transfusion therapy.
3) Hand washing is essential because patients are often asplenic.
4) If the patient has a fever, antibiotic prophylaxis may be indicated.
5) To provide pain medication per order around the clock

 

 

____  19.   The nurse is providing care to a child diagnosed with cancer. Laboratory results indicate anemia. On the basis of the laboratory results, which clinical manifestations do(es) the nurse anticipate? (Select all that apply.)

1) Fever
2) Fatigue
3) Bleeding
4) Headache
5) Tachycardia

 

 

____  20.   Which general manifestations should the nurse monitor for when conducting a physical assessment for a pediatric client who is diagnosed with cancer? (Select all that apply.)

1) Infection
2) Polycythemia
3) Petechiae
4) Pain
5) Cachexia