PEDIATRIC NURSING
Practice Exam 101-200 with Answers and Rationale
Practice Exam 101-200 with Answers and Rationale
101.While performing physical assessment of a 12
month-old, the nurse notes that the infant’s anterior fontanelle is still
slightly open. Which of the following is the nurse’s most appropriate action?
a.
Notify
the physician immediately because there is a problem.
b.
Perform
an intensive neurologic examination.
c.
Perform
an intensive developmental examination.
d.
Do
nothing because this is a normal finding for the age.
D. The anterior fontanelle typically closes anywhere between 12 to 18
months of age. Thus, assessing the anterior fontanelle as still being slightly
open is a normal finding requiring no further action. Because it is normal
finding for this age, notifying he physician or performing additional
examinations are inappropriate.
102.When teaching a mother about introducing solid foods
to her child, which of the following indicates the earliest age at which this
should be done?
a.
1
month
b.
2
months
c.
3
months
d.
4
months
D. Solid foods are not recommended before age 4 to 6 months because of
the sucking reflex and the immaturity of the gastrointestinal tract and immune
system. Therefore, the earliest age at which to introduce foods is 4 months.
Any time earlier would be inappropriate.
103.The infant of a substance-abusing mother is at risk
for developing a sense of which of the following?
a.
Mistrust
b.
Shame
c.
Guilt
d.
Inferiority
A. According to Erikson, infants need to have their needs met
consistently and effectively to develop a sense of trust. An infant whose needs
are consistently unmet or who experiences significant delays in having them met,
such as in the case of the infant of a substance-abusing mother, will develop a
sense of uncertainty, leading to mistrust of caregivers and the environment.
Toddlers develop a sense of shame when their autonomy needs are not met
consistently. Preschoolers develop a sense of guilt when their sense of
initiative is thwarted. Schoolagers develop a sense of inferiority when they do
not develop a sense of industry.
104.Which of the following toys should the nurse recommend
for a 5-month-old?
a.
A big
red balloon
b.
A
teddy bear with button eyes
c.
A
push-pull wooden truck
d.
A
colorful busy box
D. A busy box facilitates the fine motor development that occurs between
4 and 6 months. Balloons are contraindicated because small children may
aspirate balloons. Because the button eyes of a teddy bear may detach and be
aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old
is too young to use a push-pull toy.
105.The mother of a 2-month-old is concerned that she may
be spoiling her baby by picking her up when she cries. Which of the following
would be the nurse’s best response?
a.
“ Let
her cry for a while before picking her up, so you don’t spoil her”
b.
“Babies
need to be held and cuddled; you won’t spoil her this way”
c.
“Crying
at this age means the baby is hungry; give her a bottle”
d.
“If
you leave her alone she will learn how to cry herself to sleep”
B. Infants need to have their security needs met by being held and
cuddled. At 2 months of age, they are unable to make the connection between
crying and attention. This association does not occur until late infancy or
early toddlerhood. Letting the infant cry for a time before picking up the
infant or leaving the infant alone to cry herself to sleep interferes with
meeting the infant’s need for security at this very young age. Infants cry for
many reasons. Assuming that the child s hungry may cause overfeeding problems
such as obesity.
106.When assessing an 18-month-old, the nurse notes a
characteristic protruding abdomen. Which of the following would explain the
rationale for this finding?
a.
Increased
food intake owing to age
b.
Underdeveloped
abdominal muscles
c.
Bowlegged
posture
d.
Linear
growth curve
B. Underdeveloped abdominal musculature gives the toddler a
characteristically protruding abdomen. During toddlerhood, food intake decreases,
not increases. Toddlers are characteristically bowlegged because the leg
muscles must bear the weight of the relatively large trunk. Toddler growth
patterns occur in a steplike, not linear pattern.
107.If parents keep a toddler dependent in areas where he
is capable of using skills, the toddle will develop a sense of which of the
following?
a.
Mistrust
b.
Shame
c.
Guilt
d.
Inferiority
B. According to Erikson, toddlers experience a sense of shame when they
are not allowed to develop appropriate independence and autonomy. Infants
develop mistrust when their needs are not consistently gratified. Preschoolers
develop guilt when their initiative needs are not met while schoolagers develop
a sense of inferiority when their industry needs are not met.
108.Which of the following is an appropriate toy for an
18-month-old?
a.
Multiple-piece
puzzle
b.
Miniature
cars
c.
Finger
paints
d.
Comic
book
C. Young toddlers are still sensorimotor learners and they enjoy the
experience of feeling different textures. Thus, finger paints would be an appropriate
toy choice. Multiple-piece toys, such as puzzle, are too difficult to
manipulate and may be hazardous if the pieces are small enough to be aspirated.
Miniature cars also have a high potential for aspiration. Comic books are on
too high a level for toddlers. Although they may enjoy looking at some of the
pictures, toddlers are more likely to rip a comic book apart.
109.When teaching parents about the child’s readiness for
toilet training, which of the following signs should the nurse instruct them to
watch for in the toddler?
a.
Demonstrates
dryness for 4 hours
b.
Demonstrates
ability to sit and walk
c.
Has a
new sibling for stimulation
d.
Verbalizes
desire to go to the bathroom
D. The child must be able to sate the need to go to the bathroom to
initiate toilet training. Usually, a child needs to be dry for only 2 hours,
not 4 hours. The child also must be able to sit, walk, and squat. A new sibling
would most likely hinder toilet training.
110.When teaching parents about typical toddler eating
patterns, which of the following should be included?
a.
Food
“jags”
b.
Preference
to eat alone
c.
Consistent
table manners
d.
Increase
in appetite
A. Toddlers become picky eaters, experiencing food jags and eating large
amounts one day and very little the next. A toddler’s food gags express a
preference for the ritualism of eating one type of food for several days at a
time. Toddlers typically enjoy socialization and limiting others at meal time.
Toddlers prefer to feed themselves and thus are too young to have table
manners. A toddler’s appetite and need for calories, protein, and fluid
decrease due to the dramatic slowing of growth rate.
111.Which of the following suggestions should the nurse
offer the parents of a 4-year-old boy who resists going to bed at night?
a.
“Allow
him to fall asleep in your room, then move him to his own bed.”
b.
“Tell
him that you will lock him in his room if he gets out of bed one more time.”
c.
“Encourage
active play at bedtime to tire him out so he will fall asleep faster.”
d.
“Read
him a story and allow him to play quietly in his bed until he falls asleep.”
D. Preschoolers commonly have fears of the dark, being left alone
especially at bedtime, and ghosts, which may affect the child’s going to bed at
night. Quiet play and time with parents is a positive bedtime routine that
provides security and also readies the child for sleep. The child should sleep
in his own bed. Telling the child about locking him in his room will viewed by
the child as a threat. Additionally, a locked door is frightening and
potentially hazardous. Vigorous activity at bedtime stirs up the child and
makes more difficult to fall asleep.
112.When providing therapeutic play, which of the
following toys would best promote imaginative play in a 4-year-old?
a.
Large
blocks
b.
Dress-up
clothes
c.
Wooden
puzzle
d.
Big
wheels
B. Dress-up clothes enhance imaginative play and imagination, allowing
preschoolers to engage in rich fantasy play. Building blocks and wooden puzzles
are appropriate for encouraging fine motor development. Big wheels and
tricycles encourage gross motor development.
113.Which of the following activities, when voiced by the
parents following a teaching session about the characteristics of school-age
cognitive development would indicate the need for additional teaching?
a.
Collecting
baseball cards and marbles
b.
Ordering
dolls according to size
c.
Considering
simple problem-solving options
d.
Developing
plans for the future
D. The school-aged child is in the stage of concrete
operations, marked by inductive reasoning, logical operations, and reversible
concrete thought. The ability to consider the future requires formal thought
operations, which are not developed until adolescence. Collecting baseball
cards and marbles, ordering dolls by size, and simple problem-solving options
are examples of the concrete operational thinking of the schoolager.
114.A hospitalized schoolager states: “I’m not afraid of
this place, I’m not afraid of anything.” This statement is most likely an
example of which of the following?
a.
Regression
b.
Repression
c.
Reaction
formation
d.
Rationalization
C. Reaction formation is the schoolager’s typical
defensive response when hospitalized. In reaction formation, expression of
unacceptable thoughts or behaviors is prevented (or overridden) by the
exaggerated expression of opposite thoughts or types of behaviors. Regression
is seen in toddlers and preshcoolers when they retreat or return to an earlier
level of development. Repression refers to the involuntary blocking of
unpleasant feelings and experiences from one’s awareness. Rationalization is
the attempt to make excuses to justify unacceptable feelings or behaviors.
115.After teaching a group of parents about accident
prevention for schoolagers, which of the following statements by the group
would indicate the need for more teaching?
a.
“Schoolagers
are more active and adventurous than are younger children.”
b.
“Schoolagers
are more susceptible to home hazards than are younger children.”
c.
“Schoolagers
are unable to understand potential dangers around them.”
d.
“Schoolargers
are less subject to parental control than are younger children.”
C. The schoolager’s cognitive level is sufficiently
developed to enable good understanding of and adherence to rules. Thus,
schoolagers should be able to understand the potential dangers around them.
With growth comes greater freedom and children become more adventurous and
daring. The school-aged child is also still prone to accidents and home
hazards, especially because of increased motor abilities and independence. Plus
the home hazards differ from other age groups. These hazards, which are potentially
lethal but tempting, may include firearms, alcohol, and medications. School-age
children begin to internalize their own controls and need less outside
direction. Plus the child is away from home more often. Some parental or
caregiver assistance is still needed to answer questions and provide guidance
for decisions and responsibilities.
116.Which of the following skills is the most significant
one learned during the schoolage period?
a.
Collecting
b.
Ordering
c.
Reading
d.
Sorting
C. The most significant skill learned during the school-age period is
reading. During this time the child develops formal adult articulation patterns
and learns that words can be arranged in structure. Collective, ordering, and
sorting, although important, are not most significant skills learned.
117.A child age 7 was unable to receive the measles,
mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would
the nurse expect to administer MMR vaccine?
a.
In a
month from now
b.
In a
year from now
c.
At age
10
d.
At age
13
C. Based on the recommendations of the American Academy of Family
Physicians and the American Academy of Pediatrics, the MMR vaccine should be
given at the age of 10 if the child did not receive it between the ages of 4 to
6 years as recommended. Immunization for diphtheria and tetanus is required at
age 13.
118.The adolescent’s inability to develop a sense of who
he is and what he can become results in a sense of which of the following?
a.
Shame
b.
Guilt
c.
Inferiority
d.
Role
diffusion
D. According to Erikson, role diffusion develops when the adolescent
does not develop a sense of identity and a sense or where he fits in. Toddlers
develop a sense of shame when they do not achieve autonomy. Preschoolers
develop a sense of guilt when they do not develop a sense of initiative. School-age
children develop a sense of inferiority when they do not develop a sense of
industry.
119.Which of the following would be most appropriate for a
nurse to use when describing menarche to a 13-year-old?
a.
A
female’s first menstruation or menstrual “periods”
b.
The
first year of menstruation or “period”
c.
The
entire menstrual cycle or from one “period” to another
d.
The
onset of uterine maturation or peak growth
A. Menarche refers to the onset of the first
menstruation or menstrual period and refers only to the first cycle. Uterine
growth and broadening of the pelvic girdle occurs before menarche.
120.A 14-year-old boy has acne and according to his
parents, dominates the bathroom by using the mirror all the time. Which of the
following remarks by the nurse would be least helpful in talking to the boy and
his parents?
a.
“This
is probably the only concern he has about his body. So don’t worry about it or
the time he spends on it.”
b.
“Teenagers
are anxious about how their peers perceive them. So they spend a lot of time
grooming.”
c.
“A
teen may develop a poor self-image when experiencing acne. Do you feel this way
sometimes?”
d.
“You
appear to be keeping your face well washed. Would you feel comfortable
discussing your cleansing method?”
A. Stating that this is probably the only concern the adolescent has and
telling the parents not to worry about it or the time her spends on it shuts
off further investigation and is likely to make the adolescent and his parents
feel defensive. The statement about peer acceptance and time spent in front of
the mirror for the development of self image provides information about the
adolescent’s needs to the parents and may help to gain trust with the
adolescent. Asking the adolescent how he feels about the acne will encourage
the adolescent to share his feelings. Discussing the cleansing method shows
interest and concern for the adolescent and also can help to identify any
patient-teaching needs for the adolescent regarding cleansing.
121.Which of the following should the nurse suspect when
noting that a 3-year-old is engaging in explicit sexual behavior during doll
play?
a.
The
child is exhibiting normal pre-school curiosity
b.
The
child is acting out personal experiences
c.
The
child does not know how to play with dolls
d.
The
child is probably developmentally delayed.
B. Preschoolers should be developmentally incapable of demonstrating
explicit sexual behavior. If a child does so, the child has been exposed to
such behavior, and sexual abuse should be suspected. Explicit sexual behavior
during doll play is not a characteristic of preschool development nor
symptomatic of developmental delay. Whether or nor the child knows how to play
with dolls is irrelevant.
122.Which of the following statements by the parents of a
child with school phobia would indicate the need for further teaching?
a.
“We’ll
keep him at home until phobia subsides.”
b.
“We’ll
work with his teachers and counselors at school.”
c.
“We’ll
try to encourage him to talk about his problem.”
d.
“We’ll
discuss possible solutions with him and his counselor.”
A. The parents need more teaching if they state that they will keep the
child home until the phobia subsides. Doing so reinforces the child’s feelings
of worthlessness and dependency. The child should attend school even during
resolution of the problem. Allowing the child to verbalize helps the child to
ventilate feelings and may help to uncover causes and solutions. Collaboration
with the teachers and counselors at school may lead to uncovering the cause of
the phobia and to the development of solutions. The child should participate
and play an active role in developing possible solutions.
123.When developing a teaching plan for a group of high
school students about teenage pregnancy, the nurse would keep in mind which of
the following?
a.
The
incidence of teenage pregnancies is increasing.
b.
Most
teenage pregnancies are planned.
c.
Denial
of the pregnancy is common early on.
d.
The
risk for complications during pregnancy is rare.
C. The adolescent who becomes pregnant typically
denies the pregnancy early on. Early recognition by a parent or health care
provider may be crucial to timely initiation of prenatal care. The incidence of
adolescent pregnancy has declined since 1991, yet morbidity remains high. Most
teenage pregnancies are unplanned and occur out of wedlock. The pregnant adolescent
is at high risk for physical complications including premature labor and
low-birth-weight infants, high neonatal mortality, iron deficiency anemia,
prolonged labor, and fetopelvic disproportion as well as numerous psychological
crises.
124.When assessing a child with a cleft palate, the nurse
is aware that the child is at risk for more frequent episodes of otitis media
due to which of the following?
a.
Lowered
resistance from malnutrition
b.
Ineffective
functioning of the Eustachian tubes
c.
Plugging
of the Eustachian tubes with food particles
d.
Associated
congenital defects of the middle ear.
B. Because of the structural defect, children with
cleft palate may have ineffective functioning of their Eustachian tubes
creating frequent bouts of otitis media. Most children with cleft palate remain
well-nourished and maintain adequate nutrition through the use of proper
feeding techniques. Food particles do not pass through the cleft and into the
Eustachian tubes. There is no association between cleft palate and congenial ear
deformities.
125.While performing a neurodevelopmental assessment on a
3-month-old infant, which of the following characteristics would be expected?
a.
A
strong Moro reflex
b.
A
strong parachute reflex
c.
Rolling
from front to back
d.
Lifting
of head and chest when prone
D. A 3-month-old infant should be able to lift the
head and chest when prone. The Moro reflex typically diminishes or subsides by
3 months. The parachute reflex appears at 9 months. Rolling from front to back
usually is accomplished at about 5 months.
126.By the end of which of the following would the nurse
most commonly expect a child’s birth weight to triple?
a.
4
months
b.
7
months
c.
9
months
d.
12
months
D. A child’s birth weight usually triples by 12
months and doubles by 4 months. No specific birth weight parameters are
established for 7 or 9 months.
127.Which of the following best describes parallel play
between two toddlers?
a.
Sharing
crayons to color separate pictures
b.
Playing
a board game with a nurse
c.
Sitting
near each other while playing with separate dolls
d.
Sharing
their dolls with two different nurses
C. Toddlers engaging in parallel play will play near each other, but not
with each other. Thus, when two toddlers sit near each other but play with
separate dolls, they are exhibiting parallel play. Sharing crayons, playing a
board game with a nurse, or sharing dolls with two different nurses are all
examples of cooperative play.
128.Which of the following would the nurse identify as the
initial priority for a child with acute lymphocytic leukemia?
a.
Instituting
infection control precautions
b.
Encouraging
adequate intake of iron-rich foods
c.
Assisting
with coping with chronic illness
d.
Administering
medications via IM injections
A. Acute lymphocytic leukemia (ALL) causes
leukopenia, resulting in immunosuppression and increasing the risk of
infection, a leading cause of death in children with ALL. Therefore, the
initial priority nursing intervention would be to institute infection control
precautions to decrease the risk of infection. Iron-rich foods help with
anemia, but dietary iron is not an initial intervention. The prognosis of ALL
usually is good. However, later on, the nurse may need to assist the child and
family with coping since death and dying may still be an issue in need of
discussion. Injections should be discouraged, owing to increased risk from
bleeding due to thrombocytopenia.
129.Which of the following information, when voiced by the
mother, would indicate to the nurse that she understands home care instructions
following the administration of a diphtheria, tetanus, and pertussis injection?
a.
Measures
to reduce fever
b.
Need
for dietary restrictions
c.
Reasons
for subsequent rash
d.
Measures
to control subsequent diarrhea
A. The pertusis component may result in fever and
the tetanus component may result in injection soreness. Therefore, the mother’s
verbalization of information about measures to reduce fever indicates
understanding. No dietary restrictions are necessary after this injection is
given. A subsequent rash is more likely to be seen 5 to 10 days after receiving
the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea
is not associated with this vaccine.
130.Which of the following actions by a community health
nurse is most appropriate when noting multiple bruises and burns on the
posterior trunk of an 18-month-old child during a home visit?
a.
Report
the child’s condition to Protective Services immediately.
b.
Schedule
a follow-up visit to check for more bruises.
c.
Notify
the child’s physician immediately.
d.
Don
nothing because this is a normal finding in a toddler.
A. Multiple bruises and burns on a toddler are signs child abuse.
Therefore, the nurse is responsible for reporting the case to Protective
Services immediately to protect the child from further harm. Scheduling a
follow-up visit is inappropriate because additional harm may come to the child
if the nurse waits for further assessment data. Although the nurse should
notify the physician, the goal is to initiate measures to protect the child’s
safety. Notifying the physician immediately does not initiate the removal of
the child from harm nor does it absolve the nurse from responsibility. Multiple
bruises and burns are not normal toddler injuries.
131.Which of the following is being used when the mother
of a hospitalized child calls the student nurse and states, “You idiot, you
have no idea how to care for my sick child”?
a.
Displacement
b.
Projection
c.
Repression
d.
Psychosis
B. The mother is using projection, the defense mechanism used when a
person attributes his or her own undesirable traits to another. Displacement is
the transfer of emotion onto an unrelated object, such as when the mother would
kick a chair or bang the door shut. Repression is the submerging of painful
ideas into the unconscious. Psychosis is a state of being out of touch with
reality.
132.Which of the following should the nurse expect to note
as a frequent complication for a child with congenital heart disease?
a.
Susceptibility
to respiratory infection
b.
Bleeding
tendencies
c.
Frequent
vomiting and diarrhea
d.
Seizure
disorder
A. Children with congenital heart disease are more prone to respiratory
infections. Bleeding tendencies, frequent vomiting, and diarrhea and seizure
disorders are not associated with congenital heart disease.
133.Which of the following would the nurse do first for a
3-year-old boy who arrives in the emergency room with a temperature of 105
degrees, inspiratory stridor, and restlessness, who is learning forward and
drooling?
a.
Auscultate
his lungs and place him in a mist tent.
b.
Have
him lie down and rest after encouraging fluids.
c.
Examine
his throat and perform a throat culture
d.
Notify
the physician immediately and prepare for intubation.
D. The child is exhibiting classic signs of
epiglottitis, always a pediatric emergency. The physician must be notified
immediately and the nurse must be prepared for an emergency intubation or
tracheostomy. Further assessment with auscultating lungs and placing the child
in a mist tent wastes valuable time. The situation is a possible
life-threatening emergency. Having the child lie down would cause additional
distress and may result in respiratory arrest. Throat examination may result in
laryngospasm that could be fatal.
134.Which of the following would the nurse need to keep in
mind as a predisposing factor when formulating a teaching plan for child with a
urinary tract infection?
a.
A
shorter urethra in females
b.
Frequent
emptying of the bladder
c.
Increased
fluid intake
d.
Ingestion
of acidic juices
A. In females, the urethra is shorter than in males. This decreases the
distance for organisms to travel, thereby increasing the chance of the child
developing a urinary tract infection. Frequent emptying of the bladder would
help to decrease urinary tract infections by avoiding sphincter stress.
Increased fluid intake enables the bladder to be cleared more frequently, thus helping
to prevent urinary tract infections. The intake of acidic juices helps to keep
the urine pH acidic and thus decrease the chance of flora development.
135.Which of the following should the nurse do first for a
15-year-old boy with a full leg cast who is screaming in unrelenting pain and
exhibiting right foot pallor signifying compartment syndrome?
a.
Medicate
him with acetaminophen.
b.
Notify
the physician immediately
c.
Release
the traction
d.
Monitor
him every 5 minutes
B. Compartment syndrome is an emergent situation and the physician needs
to be notified immediately so that interventions can be initiated to relieve
the increasing pressure and restore circulation. Acetaminophen (Tylenol) will
be ineffective since the pain is related to the increasing pressure and tissue
ischemia. The cast, not traction, is being used in this situation for
immobilization, so releasing the traction would be inappropriate. In this
situation, specific action not continued monitoring is indicated.
136.At which of the following ages would the nurse expect
to administer the varicella zoster vaccine to child?
a.
At
birth
b.
2
months
c.
6
months
d.
12
months
D. The varicella zoster vaccine (VZV) is a live
vaccine given after age 12 months. The first dose of hepatitis B vaccine is
given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18
months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster
at 4 to 6 years.
137.When discussing normal infant growth and development
with parents, which of the following toys would the nurse suggest as most
appropriate for an 8-month-old?
a.
Push-pull
toys
b.
Rattle
c.
Large
blocks
d.
Mobile
C. Because the 8-month-old is refining his gross
motor skills, being able to sit unsupported and also improving his fine motor
skills, probably capable of making hand-to-hand transfers, large blocks would
be the most appropriate toy selection. Push-pull toys would be more appropriate
for the 10 to 12-month-old as he or she begins to cruise the environment.
Rattles and mobiles are more appropriate for infants in the 1 to 3 month age
range. Mobiles pose a danger to older infants because of possible
strangulation.
138.Which of the following aspects of psychosocial
development is necessary for the nurse to keep in mind when providing care for
the preschool child?
a.
The
child can use complex reasoning to think out situations.
b.
Fear
of body mutilation is a common preschool fear
c.
The
child engages in competitive types of play
d.
Immediate
gratification is necessary to develop initiative.
B. During the preschool period, the child has mastered a sense of
autonomy and goes on to master a sense of initiative. During this period, the
child commonly experiences more fears than at any other time. One common fear
is fear of the body mutilation, especially associated with painful experiences.
The preschool child uses simple, not complex, reasoning, engages in
associative, not competitive, play (interactive and cooperative play with
sharing), and is able to tolerate longer periods of delayed gratification.
139.Which of the following is characteristic of a
preschooler with mid mental retardation?
a.
Slow
to feed self
b.
Lack
of speech
c.
Marked
motor delays
d.
Gait
disability
A. Mild mental retardation refers to development
disability involving an IQ 50 to 70. Typically, the child is not noted as being
retarded, but exhibits slowness in performing tasks, such as self-feeding,
walking, and taking. Little or no speech, marked motor delays, and gait
disabilities would be seen in more severe forms mental retardation.
140.Which of the following assessment findings would lead
the nurse to suspect Down syndrome in an infant?
a.
Small
tongue
b.
Transverse
palmar crease
c.
Large
nose
d.
Restricted
joint movement
B. Down syndrome is characterized by the following a transverse palmar
crease (simian crease), separated sagittal suture, oblique palpebral fissures,
small nose, depressed nasal bridge, high-arched palate, excess and lax skin,
wide spacing and plantar crease between the second and big toes,
hyperextensible and lax joints, large protruding tongue, and muscle weakness.
141.While assessing a newborn with cleft lip, the nurse
would be alert that which of the following will most likely be compromised?
a.
Sucking
ability
b.
Respiratory
status
c.
Locomotion
d.
GI
function
A. Because of the defect, the child will be unable
to from the mouth adequately around nipple, thereby requiring special devices
to allow for feeding and sucking gratification. Respiratory status may be
compromised if the child is fed improperly or during postoperative period,
Locomotion would be a problem for the older infant because of the use of
restraints. GI functioning is not compromised in the child with a cleft lip.
142.When providing postoperative care for the child with a
cleft palate, the nurse should position the child in which of the following
positions?
a.
Supine
b.
Prone
c.
In an
infant seat
d.
On the
side
B. Postoperatively children with cleft palate should be placed on their
abdomens to facilitate drainage. If the child is placed in the supine position,
he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying
does not facilitate drainage as well as the prone position.
143.While assessing a child with pyloric stenosis, the
nurse is likely to note which of the following?
a.
Regurgitation
b.
Steatorrhea
c.
Projectile
vomiting
d.
“Currant
jelly” stools
C. Projectile vomiting is a key symptom of pyloric
stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in
malabsorption disorders such as celiac disease. “Currant jelly” stools are
characteristic of intussusception.
144.Which of the following nursing diagnoses would be
inappropriate for the infant with gastroesophageal reflux (GER)?
a.
Fluid
volume deficit
b.
Risk
for aspiration
c.
Altered
nutrition: less than body requirements
d.
Altered
oral mucous membranes
D. GER is the backflow of gastric contents into the
esophagus resulting from relaxation or incompetence
of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous
membranes occurs with this disorder. Fluid volume deficit, risk for aspiration,
and altered nutrition are appropriate nursing diagnoses.
145.Which of the following parameters would the nurse
monitor to evaluate the effectiveness of thickened feedings for an infant with
gastroesophageal reflux (GER)?
a.
Vomiting
b.
Stools
c.
Uterine
d.
Weight
A. Thickened feedings are used with GER to stop the
vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate
the effectiveness of using the thickened feedings. No relationship exists
between feedings and characteristics of stools and uterine. If feedings are
ineffective, this should be noted before there is any change in the child’s
weight.
146.Discharge teaching for a child with celiac disease
would include instructions about avoiding which of the following?
a.
Rice
b.
Milk
c.
Wheat
d.
Chicken
C. Children with celiac disease cannot tolerate or
digest gluten. Therefore, because of its gluten content, wheat and
wheat-containing products must be avoided. Rice, milk, and chicken do not
contain gluten and need not be avoided.
147.Which of the following would the nurse expect to
assess in a child with celiac disease having a celiac crisis secondary to an
upper respiratory infection?
a.
Respiratory
distress
b.
Lethargy
c.
Watery
diarrhea
d.
Weight
gain
C. Episodes of celiac crises are precipitated by infections, ingestion
of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac
crisis is typically characterized by severe watery diarrhea. Respiratory
distress is unlikely in a routine upper respiratory infection. Irritability,
rather than lethargy, is more likely. Because of the fluid loss associated with
the severe watery diarrhea, the child’s weight is more likely to be decreased.
148.Which of the following should the nurse do first after
noting that a child with Hirschsprung disease has a fever and watery explosive
diarrhea?
a.
Notify
the physician immediately
b.
Administer
antidiarrheal medications
c.
Monitor
child ever 30 minutes
d.
Nothing,
this is characteristic of Hirschsprung disease
A. For the child with Hirschsprung disease, fever
and explosive diarrhea indicate enterocolitis, a life-threatening situation.
Therefore, the physician should be notified immediately. Generally, because of
the intestinal obstruction and inadequate propulsive intestinal movement,
antidiarrheals are not used to treat Hirschsprung disease. The child is acutely
ill and requires intervention, with monitoring more frequently than every 30
minutes. Hirschsprung disease typically presents with chronic constipation.
149.A newborn’s failure to pass meconium within the first
24 hours after birth may indicate which of the following?
a.
Hirschsprung
disease
b.
Celiac
disease
c.
Intussusception
d.
Abdominal
wall defect
A. Failure to pass meconium within the first 24 hours after birth may
be an indication of Hirschsprung disease, a congenital anomaly resulting in
mechanical obstruction due to inadequate motility in an intestinal segment.
Failure to pass meconium is not associated with celiac disease,
intussusception, or abdominal wall defect.
150.When assessing a child for possible intussusception,
which of the following would be least likely to provide valuable information?
a.
Stool
inspection
b.
Pain
pattern
c.
Family
history
d.
Abdominal
palpation
C. Because intussusception is not believed to have a familial tendency,
obtaining a family history would provide the least amount of information. Stool
inspection, pain pattern, and abdominal palpation would reveal possible
indicators of intussusception. Current, jelly-like stools containing blood and
mucus are an indication of intussusception. Acute, episodic abdominal pain is
characteristics of intussusception. A sausage-shaped mass may be palpated in
the right upper quadrant.
151.
The
mother of a 9 month-old infant is concerned that the head circumference of her
baby is greater than the chest circumference. The BEST response by the nurse
is:
A. “These circumference
normally are the same, but in some babies this just differs.”
B. “Perhaps your baby was
small for gestational age or premature.”
C. “This is normal until
the age of 1 year, when the chest will be greater.”
D. “Let me ask you a few questions, and perhaps
we can figure out the cause of this difference.”
152. Which of the
following approaches would work best when the nurse is communicating with an
infant?
A. Use an adult voice
just as you would for anyone.
B. Communicate through
the caregivers.
C. Allow the child time
to warm up to the nurse.
D. Respond only after the child cries for a
while.
153. The nurse assessing
newborn babies and infants during their hospital stay after birth will notice
which of the following symptoms as a primary manifestation of Hirschsprung’s
disease?
A. A fine rash over the
trunk
B. Failure to pass
meconium during the first 24 to 48 hours after birth
C. The skin turns yellow
and then brown over the first 48 hours of life
D. High-grade fever
154.
The
nurse assessing a child or adolescent with a diagnosis of dysrhytmic disorder
would find which of the following symptoms?
A. Labile mood and
hyperactive thyroid with an increase in circulating thyroid hormones and
associated symptoms
B. Severe shaking of the
hands when trying to hold a glass of water or other object
C. A depression that is
deeper, more acute, and more likely to lead to suicide than major depressive
disorder
D. A depressed or irritable mood for most
of the day, on most days, for 2 or more years and low energy or fatigue.
155.
One
of four factors describing the experience of sexually abused children and the
effect it has on their growth and development is stigmatization that occurs
when:
A. a child blames him or
herself for the sexual abuse and begins to withdraw and isolate
B. newspapers and the media
don’t keep sexual abuse private and accidentally or on purpose reveal the name
of the victim
C. the child has been
blamed by the abuser for his or her sexual behaviors, saying that the child
asked to be touched or did not make the abuser to stop
D. the child’s agony is
shared by other members of the family or friends when the sexual abuse becomes
public knowledge
156.
Infant
head control is judged by the:
A. ability to hold the
head without support
B. presence or absence of
head lag
C. rigidity of the neck
and head
D. amount of neck
wrinkling
157. Following circumcision of a 1-day-old
infant, what is the most effective strategy for ensuring urinary elimination?
A. Feeding the infant
B. Having nonconstrictive gauze
over the penis.
C. Keeping the infant on his
side.
D. Checking for first void
postcircumcision.
Rationale: A (pg 965) the infant has had feeding restrictions prior to the
circumcision so feeding him afterwards will satisfy him with fluid to help him
void. The gauze is to prevent irritation
friction from covers on the penis; side-lying position has no influence on the
urethra to expel urine; the first void is an evaluate measure and does not lead to voiding as feeding would.
158. The mother of a child in well-baby clinics
asks the nurse which immunizations contain live virus. What is the nurse’s best
response?
A. MMR and varicella.
B. Hib and PPV.
C. DTaP and IPV
D. DTaP and Hib.
Rationale: A (pg 958) The measles , mumps, and rubella vaccine
(MMR) and varicella (chickenpox) contain
lives virus.
159. The nurse is caring
for a 2- week- old baby who is showing clinical manifestations of heart murmur,
widened pulse pressure, cardiomegaly, bounding pulses, and tachycardia. The
assessment finding indicates that which of the following shunt systems from
fetal circulation has failed to close?
A. Ductus venosus
B. Ductus
arteriosus
C. Ligamentum
arteriosum
D. Foramen
ovale.
Rationale: A. (pg. 935) Heme in the stool can be early warning sign
of necrotizing enterocolitis. All the other activities should be assessed prior
to each feeding.
160.
The nurse has been discussing
promotion of growth and development with a family whose 15-month old son has a
cyanotic heart defect. Which statement by the father indicates a need for
further teaching?
A. ‘’I need to feed him slowly and allow frequent rest periods.’’
B. ‘’I need to play quiet games
and activities with my son.’’
C. ‘’I need to provide highly
nutritious foods.’’
D. ‘’I need to limit my son’s
interactions with other children.’’
Rationale: A. (pg. 913) Normal height is 29-32 inches; normal
weight is between 19 to 27 pounds.
161.
The mother of a newborn learns
that her infant son has lost 8 ounces since his birth 2 days ago. The nurse
explains that this weight loss is normal. What explanation will the nurse
provide for the weight loss result?
A. Feeding infants every 4 hours instead of every 3 hours.
B. Loss of fluid from the cord
stump.
C. Limited food intake since
birth.
D. Regurgitation of
feedings.
Rationale: A. (pg. 911) The
most common side effect of epidural anesthesia is a sudden drop in material
blood pressure, which can compromise fetal blood flow.
162.
The nurse is playing with a 2
year-old child with tetralogy of Fallot, who suddenly squats on the floor. What
is the best initial nursing action?
A. Return the child to bed
immediately.
B. Allow the child to remain in that position.
C. Place the child in a chair.
D. Call the physician
immediately.
Rationale: B. (pg. 909) The squatting position serves to decrease
venous return by occluding the femoral vein through hip flexion, to lessen the
workload on the right side of the heart, and to increase arterial oxygen
saturation. Returning the child to bed or placing in a chair would not lessen
workload on the right side of the heart, and to increase arterial oxygen
saturation. Returning the child to bed or placing in a chair would not lessen
the heart’s workload as the squatting does. They physician would already be
award of this condition.
163.
A 21/2-year-old
child is hospitalized for severe otitis media. He was toilet trained prior to
being hospitalized but is having “accidents” now that he is in hospital. What
is the best explanation for this change in behavior?
A. It is unrealistic for a child
at age 21/2 to be toilet trained.
B. The nurse did not show the
child where the bathroom is located.
C. A child of this age needs a
parent available to assist with toileting.
D. It is normal for a child to experience regressive behavior due to
the stress of hospitalization.
Rationale: D. (pg. 893) Regressive behavior is frequently seen in
children who are under stress. This age is appropriate for toilet- training and
the child could be assisted by anyone.
164.
A 2-year old is admitted to
the hospital with meningitis. What is the highest priority?
A. Inform the parents of the
child’s condition.
B. Maintain a quiet environment.
C. Maintain for changes in intracranial pressure.
D. Maintain bed rest.
Rationale: C. (pg. 893) All are important: however, changes in
intracranial pressure can be life- threatening.
165.
A young child with bronchial
asthma is admitted for the second time in 1 month. Cystic fibrosis is
suspected. Which physiological assessment is most likely to be seen in the
child with cystic fibrosis?
A. Expectoration of large amounts
of thin, frothy mucus with coughing, and bubbling ronchi for lung sounds.
B. High serum sodium chloride
levels and low sodium chloride levels in the sweat.
C. Large, loose, foul smelling tools with normal frequency or a
chronic diarrhea of unformed stools.
D. Obesity from malabsorption of
fats and polycythemia from poor oxygenation of tissues.
Rationale: C. (pg. 892) The obstruction of the pancreatic duct with
thick mucus prevents digestive enzymes from entering the duodenum, thus
preventing digestion of food. Undigested food (mainly fats and protein) are
excreted in the stool, increasing the bulk to twice the normal amount.
Expectoration is very difficult because the excess mucus produced is tenacious
and viscous. Elevated sweat chloride above 60 mmol/L is consistent with the
diagnosis of cystic fibrosis.
166.
One
of the mothers verbalized that her child has difficulty realizing that the
amount of orange juice in two cups of different diameters is the same because a
taller amount appears in one cup. After explaining the child’s cognitive
development, the mother would correctly verbalized that this perception occurs
in the preschooler because
A. intuitional
thought has not matured.
B. preschoolers are unaware of the property of
conservation.
C. this
requires concrete thinking.
D. preschoolers
are unaware of the concept of permanence.
Rationale:
B. Conservation is the ability to discern that a change in shape does not
change volume. It is learned in the school-age period.
167.
A
mother of a 4-year-old tells the nurse that her son is a "picky
eater." The nurse should inform the mother that she should:
A. Increase
the amount of carbohydrates in the daily menu plan.
B. Administer
vitamins twice a day to her child.
C. Be
more concerned with the quantity of food than the quality of food.
D. Recognize this is common for preschoolers as
their caloric requirements have decreased slightly.
Rationale: D. The preschooler
will be influenced by others' eating habits and demonstrate their likes and
dislikes for food preferences. The caloric requirement decreases slightly, to
90 kcal/kg/day. Quality, not quantity, is important. It is not necessary to
give vitamins after infancy unless the child is at nutritional risk.
168. The nurse is aware
that preschoolers are afraid of the dark. When planning care for this child,
the nurse would
A. appreciate that fear of the dark is universal
with preschoolers.
B. ask
if an animal frightened the preschooler lately.
C. begin
a behavior modification program for the preschooler.
D. perform
a Denver Developmental Screening Test to determine developmental age.
Rationale:
A. Fear of the dark is an almost universal fear among preschoolers because
of their keen imagination.
169.
A
4-year-old tells the nurse he has an imaginary friend. His parents are
concerned because he refuses to do anything without his friend’s help. Which of
the following nursing diagnoses is most applicable for his family?
A. Compromised
family coping related to abnormal behavior of child.
B. Deficient knowledge of normal preschool
development.
C. Disturbed
thought processes related to deep-set psychological need.
D. Social
isolation related to unwillingness to relate except through imaginary friend.
Rationale:
B. Because a preschooler’s imagination is at a peak, imaginary friends are
not uncommon.
170.
The
developmental task of preschoolers is to achieve a sense of
A. Autonomy
versus shame and doubt.
B. cognition versus attitude.
C. Initiative
versus Guilt.
D. accomplishment
versus inefficiency.
Rationale:
C. Developing a sense of initiative, or learning how to do things, is the
developmental task of the preschool period.
171.
The
appropriate way that Bennet would advise a toddler’s mother to handle temper
tantrums would be to:
A. appear to ignore them.
B. distract
him with a toy when he begins breath holding.
C. promise
him a special activity if he will stop.
D. mimic
his behavior by also holding her breath.
Rationale:
A. Rewarding temper tantrums can teach children that they are an effective
method of interaction. Ignoring tantrums teaches that they are ineffective.
172.
The
nurse plans to conduct health teaching focusing on toilet training. Which of
the following is the most important factor for successful toilet training?
A. Age
of the child
B. Developmental readiness of the child
C. Toilet
training at scheduled time
D. Primary
caregiver’s flexibility
173.
One
of the toddlers’ mother verbalized concern because her child takes her blanket
everywhere. Which advice would be most appropriate for her regarding this?
A. Have
her daughter evaluated by a child psychologist.
B. Understand that this is probably a normal
event.
C. Make
subtle efforts to remove the blanket.
D. Destroy
the blanket by cutting off a strip from it every day.
Rationale:
B. Blankets or favorite toys serve as transitional objects or security
objects.
147.
Which
measure would Bennet suggest an infant’s mother use to relieve teething
discomfort?
A. Provide
her with a fluid diet for 2 days.
B. Offer
her Aspergum to chew.
C. Ask
her pediatrician for a sedative for her.
D. Give her a cold teething ring to chew.
Rationale:
D. Cold can be very soothing for
the tender gum lines during teething. A sedative is not necessary for normal
teething discomfort.
175.
During
interaction with the parents, the mother of a 2-year-old tells Cherie, that she
is constantly scolding him for having wet pants. She says her son was trained
at 12 months, but since he started to walk, he wets all the time. Which nursing
diagnosis would be most applicable?
A. Deficient parental knowledge related to
inappropriate method for toilet training.
B. Excess
fluid volume related to inability to control urination.
C. Ineffective
coping related to lack of self-control of 2-year-old.
D. Total
urinary incontinence related to delayed toilet training.
Rationale:
A. It is probable that a child toilet trained at 12 months was not truly
trained; his mother was trained to remind him or place him on a toilet
frequently during the day. When the child begins to play independently, the
“training” is no longer effective.
176.
The
best way for parents to aid a toddler in achieving his developmental task would
be to
A. Urge
him to dress himself completely alone.
B. give
him small household chores to do.
C. help
him learn to count.
D. Allow him to make simple decisions.
Rationale:
D. Making decisions is primary
practice toward achieving independence.
177.
In
evaluating the health teaching on breastfeeding, which of the following
statement made by the mother, would reveal correct understanding on breastfed
infants?
A. Stools
of breastfed infants are usually harder than those of bottle-fed infants.
B. Breastfed
infants usually have fewer stools than bottle-fed infants.
C. Breastfed infants are less likely to be
constipated than bottle-fed infants.
D. Stools
of breastfed infants tend to have a strong odor.
Rationale: C. The stools of
breastfed infants tend to be yellow and looser than those of bottle-fed babies.
178.
According
to the mother, her 10-year-old becomes very upset and expresses sympathy for
his friend whose dog has just died. The nurse would document that this kind of
reaction is an indication that the child has achieved which step in cognitive
thought?
A. Conservation.
B. Accommodation.
C. Comprehension.
D. Irreversibility.
Rationale:
B. Accommodation means the ability to view situations from another’s view.
179.
One
of the parents of a school-age child with school phobia have taken her to three
different psychiatrists trying to resolve this problem. Based on this, which of
the following nursing diagnoses would be most appropriate?
A. Disturbed
thought processes related to difficulty in school adjustment.
B. Compromised parental coping related to
inability to enforce school attendance.
C. Noncompliance
with expected school behavior related to school phobia.
D. Ineffective
tissue perfusion, cerebral, related to anxiety over attending school.
Rationale:
B. School phobia may be a problem of both parent and child.
180.
The
parents of a 10-year-old are concerned because she does not eat breakfast
before she leaves for school. The best suggestion that Nurse Maria could give
regarding this would be to
A. allow
the child to take a breakfast to eat on the school bus.
B. limit
privileges if a complete breakfast is not eaten.
C. be certain to act as role models by eating
breakfast themselves.
D. encourage
the child to collect prizes from cereal she eats.
Rationale:
C. Role modeling is as important in building good nutrition habits as it
is in other aspects of the child’s life.
181.
A
mother tells Nurse Maria that her 6-year-old has been biting his fingernails
since he began first grade. After analyzing the cause of this as increased
stress, which of the following would Nurse Maria advice the mother regarding
this problem ?
A. Encourage
the child to drink more milk for stronger nails.
B. distract
the child by teaching him a new skill, such as whistling.
C. Allow some time every day for the child to
talk about new experiences.
D. allow
the child to choose a reward for not biting his nails.
Rationale:
C. Beginning school can be a time of extreme stress for children. Allowing them time to discuss these
experiences allows them to put experiences in perspective and begin to deal
with them.
182.
Nurse
Maria explains to the parents that the Boy Scouts is an organization that
continues to be a favorite with school-age boys because :
A. Fathers
participate in Boy Scouts.
B. no
girls are included in the organization.
C. Merit badges require completing small tasks
for rewards.
D. hiking
is a favorite school-age activity.
Rationale:
C. An organization that allows school-age children to complete small tasks
and receive rewards helps develop a sense of industry.
183.
Which
of the following is considered as the first sign of puberty that Angel will
notice?
A. "The appearance of breast buds."
B. "An
increase in energy and appetite."
C. "The
occurrence of the first menarche."
D. "Appearance
of body odor."
Rationale:
A. Puberty is a process that brings about the development of secondary sex
characteristics, which begin, with the appearance of breast buds at 9 to 11
years followed by the growth of pubic hair. Menarche follows approximately 1
year later. Body odor may result later because of an increase in secretions
from the apocrine glands.
184.
Angel
refuses to wear the clothes her mother bought for her. She wants to look like
the other kids at school and wear clothes like they wear. The nurse would
explain that this behavior is an example of teenage rebellion related to
internal conflicts of:
A. Autonomy
vs. shame and doubt.
B. Trust
vs. mistrust.
C. Identity vs. role confusion.
D. Initiative
vs. inferiority.
Rationale:
C. Erikson's theory of psychosocial development states that the child is
faced with conflicts that need to be resolved. Erikson identifies stages of
personality development. Identity vs. role confusion (12 to 19 years) is a
period when adolescents search for answers regarding their future. During this
time, the child rejects the identity presented by his parents and attempts to
create his own identity. Identity is often based on peers. Positive outcomes
result in optimism and confidence. Negative outcomes result in sense of
purposelessness or deviance.
185.
When
encouraging Angel to develop and maintain her sense of identity, the nurse
would plan to
A. Provide the opportunity for individual
decision making.
B. Provide
physical comfort to the individual.
C. Ask
the parents what the adolescent is capable of doing.
D. Provide
care until the adolescent insists on being independent.
Rationale:
A. Knowing who you are includes how to make decisions to advance your
welfare. Providing opportunities to do this is important.
186.
Safety
is a major concern when taking care of teen-agers. In conducting health
education for Angel and her peers, the primary focus of the nurse would be on
which of the following areas?
A. Falls
B. Motor vehicle accidents
C. Firearms
D. Bar
related accidents
Rationale:
B. Accidents are the leading cause
of death and injury among adolescents. Motor vehicular accidents and sport
injuries are the most common accidents. Teenagers may use driving as an outlet
for stress, as a way to assert independence or as a way to impress peers.
Adolescents are at risk for sport injuries because their coordination skills
are not yet fully developed.
187.
Angel
is concerned with the presence of acne on her face. After attending lecture on
this, she would correctly identify that the basic cause of acne is
A. lack
of showering adequately after gym class.
B. activation of androgen hormones.
C. vitamin
deficiency from an inadequate diet.
D. thyroid
gland secretions increasing with adolescence.
Rationale:
B. As androgen rises with puberty, sebaceous glands are activated to
increase production of sebum, which leads to plugging of ducts (comedones).
188. Baby girl Luisa was
born large for gestational age. After being delivered vaginally, this infant
should be carefully assessed for:
A. Increased intracranial pressure
B. Hypothermia
C. Decreased red blood
levels (anemia)
D. Hyperglycemia
Answer: A
189. A pregnant woman’s blood test revealed a very
low hemoglobin levels. The physician considers the woman severely anemic. Which
of the following is the most likely effect on the fetus if the woman is
severely anemic during pregnancy?
A. Hemorrhage could be possible
A. Hemorrhage could be possible
B. Erythroblastosis fetalis
C. Small for gestational age (SGA) baby
D. Large for gestational age (LGA) fetus
Answer: D
Anemia is a condition where there is a reduced amount of hemoglobin. Hemoglobin is needed to supply the fetus with adequate oxygen. Oxygen is needed for normal growth and development of the fetus.
C. Small for gestational age (SGA) baby
D. Large for gestational age (LGA) fetus
Answer: D
Anemia is a condition where there is a reduced amount of hemoglobin. Hemoglobin is needed to supply the fetus with adequate oxygen. Oxygen is needed for normal growth and development of the fetus.
190. At what APGAR score at 5 minutes after birth
should resuscitation be initiated?
A. 1-2
B. 3-5
C. 6-8
D. 9-10
Answer: A
An APGAR of 1-2 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10.
A. 1-2
B. 3-5
C. 6-8
D. 9-10
Answer: A
An APGAR of 1-2 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10.
191. A newborn of 4 hours
displays grunting respirations and a respiratory rate of 70 breaths/minute. The
priority nursing intervention would be to:
A. Begin resuscitative measures and call for
help.
B. Continue to monitor
respiratory status variations are normal.
C. Obtain vital signs
every 15 minutes.
D. Transfer the newborn
to the mother’s room for feeding.
Answer: A
192. Which of the following characteristics will
distinguish a postmature neonate at birth?
A. Minimal vernix caseosa, leather-like skin, observable dryness
A. Minimal vernix caseosa, leather-like skin, observable dryness
B. Lanugo very observable on the shoulders and
vernix caseosa in the skin
C. Plenty of lanugo and vernix caseosa covering the body
D. Pinkish skin with good turgor
C. Plenty of lanugo and vernix caseosa covering the body
D. Pinkish skin with good turgor
1Answer: A
A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished.
A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished.
193. The following are signs and symptoms of fetal
distress EXCEPT:
A. FHR is 160 bpm, weak and irregular
B. The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm
A. FHR is 160 bpm, weak and irregular
B. The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm
C. Fetal heart rate (FHR) decreased during a
contraction and persists even after the uterine contraction ends
D. The FHR is less than 120 bpm or over 160 bpm
Answer: B
The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usually goes down but must return to its pre-contraction rate after the contraction ends.
D. The FHR is less than 120 bpm or over 160 bpm
Answer: B
The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usually goes down but must return to its pre-contraction rate after the contraction ends.
194. In which position
should the newborn with intracranial hemorrhage be placed?
A. Prone
B. Side-lying
C. Slightly elevated head of bed
D. Supine
Answer: C
195.
Which action should nurse Marian include in the care plan for a 2 month old
with heart failure?
A.
Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C.
Bathe the infant and administer medications before feeding.
D.
Weigh and bathe the infant before feeding.
Answer: B
Rationale: Because feeding
requires so much energy, an infant with heart failure should rest before
feeding.
196.
When teaching parents of a neonate the proper position for the neonate’s sleep,
the nurse Patricia stresses the importance of placing the neonate on his back
to reduce the risk of which of the following?
a.
Aspiration
b. Sudden infant death syndrome (SIDS)
c.
Suffocation
d.
Gastroesophageal reflux (GER)
Answer: B
Rationale: Supine positioning
is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is
slightly increased with the supine position.
Suffocation would be less likely with an infant supine than prone and
the position for GER requires the head of the bed to be elevated.
197. A decision to withhold "extraordinary
care" for a newborn with severe abnormalities is actually:
A. The same as
pediatric euthanasia
B. A decision to let the newborn die
C. Presuming that the newborn has no rights
D. Unethical and illegal medical nursing practice
B. A decision to let the newborn die
C. Presuming that the newborn has no rights
D. Unethical and illegal medical nursing practice
Answer B
Explanation: A. Euthanasia is a deliberate intervention to cause death. B. Based on the family's decision, extraordinary care does not have to be employed; the infant's basic needs are met, and nature is allowed to take its course. C. If the infant's physical needs are met and comfort is provided, the infant's rights are not ignored; "extraordinary," not "all," care is being withheld. D. It is neither unethical or illegal to withhold extraordinary treatments; once such treatment is started, it becomes a legal issue.
Explanation: A. Euthanasia is a deliberate intervention to cause death. B. Based on the family's decision, extraordinary care does not have to be employed; the infant's basic needs are met, and nature is allowed to take its course. C. If the infant's physical needs are met and comfort is provided, the infant's rights are not ignored; "extraordinary," not "all," care is being withheld. D. It is neither unethical or illegal to withhold extraordinary treatments; once such treatment is started, it becomes a legal issue.
198. An infant is born with a bilateral cleft
palate and right cleft lip. Plans are made to begin reconstruction immediately.
Nursing intervention to promote parent-infant bonding should include:
A. Demonstrating
a positive acceptance of the infant.
B. Placing the baby in a nursery away from view of the general public.
C. Explaining to the parents that the infant will look normal after the surgery.
D. Encouraging the parents to limit contact with the infant until after surgery.
B. Placing the baby in a nursery away from view of the general public.
C. Explaining to the parents that the infant will look normal after the surgery.
D. Encouraging the parents to limit contact with the infant until after surgery.
Answer A
Explanation: A. By demonstrating acceptance of the infant, without regard for the defect, the nurse acts as a role model for the parents, thus enhancing their acceptance. B. Infants with cleft palates can remain in the newborn nursery; they should not be hidden. C. This is false reassurance; it does not promote parent-infant bonding.D. The parents should be encouraged to have frequent contact with their infant to promote bonding.
Explanation: A. By demonstrating acceptance of the infant, without regard for the defect, the nurse acts as a role model for the parents, thus enhancing their acceptance. B. Infants with cleft palates can remain in the newborn nursery; they should not be hidden. C. This is false reassurance; it does not promote parent-infant bonding.D. The parents should be encouraged to have frequent contact with their infant to promote bonding.
199. Smoking is contraindicated in pregnancy
because
A. Nicotine causes vasodilation of the mother’s blood vessels
B. Nicotine will cause vasoconstriction of the fetal blood vessels
C. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus
D. The smoke will make the fetus feel dizzy
Answer: C
Carbon monoxide is one of the substances found in cigarette smoke. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus.
A. Nicotine causes vasodilation of the mother’s blood vessels
B. Nicotine will cause vasoconstriction of the fetal blood vessels
C. Carbon monoxide binds with the hemoglobin of the mother reducing available hemoglobin for the fetus
D. The smoke will make the fetus feel dizzy
Answer: C
Carbon monoxide is one of the substances found in cigarette smoke. This substance diminishes the ability of the hemoglobin to bind with oxygen thus reducing the amount of oxygenated blood reaching the fetus.
200.
Baby Tina a 3-month-old infant just had a cleft lip and palate repair. What
should the nurse do to prevent trauma to operative site?
A.
Avoid touching the suture line, even when cleaning.
B.
Place the baby in prone position.
C.
Give the baby a pacifier.
D. Place the
infant’s arms in soft elbow restraints.
Answer: D
Soft restraints from the upper
arm to the wrist prevent the infant from touching her lip but allow him to hold
a favorite item such as a blanket. Because they could damage the operative
site, such as objects as pacifiers, suction catheters, and small spoons
shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone
position may rub her face on the sheets and traumatize the operative site. The
suture line should be cleaned gently to prevent infection, which could
interfere with healing and damage the cosmetic appearance of the repair.
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