ATI MATERNAL-
NEWBORN FREQUENTLY
TESTED QUESTIONS AND
ANSWERS SOLUTION
Nursing
Liberty University
(LU)
114 pag.
ATI MATERNAL-NEWBORN FREQUENTLY TESTED
QUESTIONS AND ANSWERS SOLUTION
1. Two days after delivery, a postpartum client prepares for discharge. What should the
nurse teach her about lochia flow?
Incorrect: Lochia does change color but goes from lochia rubra (bright red) on days 1-3, to lochia
serosa (pinkish brown) on days 4-9, to lochia alba (creamy white) days 10-21.
Incorrect: Numerous clots are abnormal and should be reported to the physician.
Incorrect: Saturation of the perineal pad is considered abnormal and may indicate postpartum
hemorrhage.
Correct: Lochia normally lasts for about 21 days, and changes from a bright red, to pinkish
brown, to creamy white.
The color of the lochia changes from a bright red to white after four days
Numerous large clots are normal for the next three to four days
Saturation of the perineal pad with blood is expected when getting up from the bed
Lochia should last for about 3 weeks, changing color every few days
2. A nurse monitors fetal well-being by means of an external monitor. At the peak of the
contractions, the fetal heart rate has repeatedly dropped 30 beats/min below the baseline. Late
decelerations are suspected and the nurse notifies the physician. Which is the rationale for
this action?
Incorrect: A nuchal cord (cord around the neck) is associated with variable decelerations, not late
decelerations.
Incorrect: Variable decelerations (not late decelerations) are associated with cord compression.
Incorrect: Late decelerations are a result of hypoxia. They are not reflective of the strength of
maternal contractions.
Correct: Late decelerations are associated with uteroplacental insufficiency and are a sign
of fetal hypoxia. Repeated late decelerations indicate fetal distress.
The umbilical cord is wrapped tightly around the fetus' neck
The fetal cord is being compressed due to rapid descent of the fetal head
Maternal contractions are not adequate enough to deliver the fetus
The fetus is not receiving adequate oxygen and is in distress
3. Which preoperative nursing interventions should be included for a client who is scheduled to
have an emergency cesarean birth?
Incorrect: Monitoring O2 saturations and administering pain medications are postoperative
interventions.
Incorrect: Taking vital signs every 15 minutes is a postoperative intervention. Instructing the
client regarding breathing exercises is not appropriate in a crisis situation when the client's
anxiety is high, because information would probably not be retained. In an emergency, there is
time only for essential interventions.
Correct: Because this is an emergency, surgery must be performed quickly. Anxiety of the
client and the family will be high. Inserting an indwelling catheter helps to keep the
bladder empty and free from injury when the incision is made.
Incorrect: The nurse should have assessed breath sounds upon admission. Breath sounds are
important if the client is to receive general anesthesia, but the anesthesiologist will be listening to
breath sounds in surgery in that case.
Monitor oxygen saturation and administer pain medication.
Assess vital signs every 15 minutes and instruct the client about postoperative care.
Alleviate anxiety and insert an indwelling catheter.
Perform a sterile vaginal examination and assess breath sounds.
4. Which nursing instruction should be given to the breastfeeding mother regarding care of the
breasts after discharge?
Incorrect: Engorgement occurs on about the third or fourth postpartum day and is a
result of the breast milk formation. The primary way to relieve engorgement is by
pumping or longer nursing. Giving a bottle of formula will compound the problem because
the baby will not be hungry and will not empty the breasts well.
Incorrect: Applying lotion to the nipples is not effective for keeping them soft. Excessive
amounts of lotion may harbor microorganisms.
Correct: In order to stimulate adequate milk production, the breasts should be pumped if
the infant is not sucking or eating well, or if the breasts are not fully emptied.
Incorrect: Using soap on the breasts dries the nipples and can cause cracking.
The baby should be given a bottle of formula if engorgement occurs.
The nipples should be covered with lotion when the baby is not nursing.
The breasts should be pumped if the baby is not sucking adequately.
The breasts should be washed with soap and water once per day.
5. A client in preterm labor is admitted to the hospital. Which classification of drugs should
the nurse anticipate administering?
Correct: Tocolytics are used to stop labor. One of the most commonly used tocolytic
drugs is ritodrine (Yutopar).
Incorrect: Anticonvulsants are used for clients with pregnancy-induced hypertension who are
likely to seize.
Incorrect: The glucocorticoids (e.g., betamethasone and dexamethasone) are used for
accelerating fetal lung maturation and production of surfactant. They are commonly used if the
membranes are ruptured or labor cannot be stopped.
Incorrect: Anti-infective are used if there is infection. Preterm labor may or may not involve
ruptured membranes with its accompanying risk of infection.
Tocolytics
Anticonvulsants
Glucocorticoids
Anti-infective
6. Which of the following are probable signs, strongly indicating pregnancy?
Incorrect: The presence of fetal heart sounds is a positive sign of pregnancy; quickening is a
presumptive Sign of pregnancy.
Incorrect: These are presumptive signs. They may indicate pregnancy or they may be caused by
other conditions, such as disease processes.
Correct: These are probable signs that strongly indicate pregnancy. Hegar’s sign is a
softening of the lower uterine segment, and Chadwick's sign is the bluish or purplish color
of the cervix as a result of the increased blood supply and increased estrogen. Ballottement
occurs when the cervix is tapped by an examiner's finger and the fetus floats upward in the
amniotic fluid and then falls downward.
Incorrect: These are presumptive signs that might indicate pregnancy, but they might be caused
by other conditions, such as disease processes.
Presence of fetal heart sounds and quickening
Missed menstrual periods, nausea, and vomiting
Hegar's sign, Chadwick's sign, and ballottement
Increased urination and tenderness of the breasts
7. Two hours after delivery the nurse assesses the client and documents that the fundus is soft,
boggy, above the level of the umbilicus, and displaced to the right side. The nurse encourages
the client to void. Which is the rationale for this nursing action?
Correct: Bladder distention can lead to postpartum hemorrhage. A full bladder displaces
the uterus causing it not to contract properly. Emptying the bladder allows the uterus to
contract more firmly.
Incorrect: A distended bladder rises out of the abdomen, causing the uterus to be displaced and
increasing the risk of hemorrhage. It does not affect the perineum.
Incorrect: Bladder distention can lead to urinary stasis and infection. This, however, does not
relate to the soft, boggy uterus or the potential for hemorrhage.
Incorrect: Massaging is uncomfortable regardless of whether the bladder is full or not. A full
bladder displaces the uterus causing it not to contract properly, which may lead to
postpartum hemorrhage.
A full bladder prevents normal contractions of the uterus.
An overdistended bladder may press against the episiotomy causing dehiscence.
Distention of the bladder can cause urinary stasis and infection.
It makes the client more comfortable when the fundus is massaged.
8. Which site is preferred for giving an IM injection to a newborn?
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for
injections in the newborn because of lack of muscle mass.
Correct: The middle third of the vastus lateralis is the preferred site for injections.
Incorrect: Ventrogluteal muscles are located in the hip area. It is not the preferred site for
injections in the newborn because of lack of muscle mass.
Incorrect: Newborns do not receive injections in the dorsogluteal site (gluteus maximus) due to
decreased muscle mass.
Ventrogluteal
Vastus lateralis
Rectus femoris
Dorsogluteal
9. During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL
of urine. How should the nurse interpret this finding?
Incorrect: Urinary tract infections are common during pregnancy and in the postpartum period.
Urinary frequency is a common finding. However, voiding large amounts of urine is not a sign of
a UTI.
Incorrect: High output renal failure occurs with injury/trauma to the kidneys. There has been no
damage to the kidneys. Incorrect: Most women do receive some IV fluids during labor and
delivery, however the IV rates are carefully calculated according to weight.
Correct: During pregnancy, the circulating blood volume increases by about 50%. In order
to get rid of the excess fluid volume after delivery, the woman experiences an increased
amount of urine output during the first few hours.
Urinary tract infection
High output renal failure
Excessive use of IV fluids during delivery
Normal diuresis after delivery
10. If a pregnant client diagnosed with gestational diabetes cannot maintain control of her
blood sugar by diet alone, which medication will she receive?
Incorrect: Glucophage is an oral hypoglycemic. Oral hypoglycemic cross the placenta and can
cause damage to the fetus. They are not used in gestational diabetes for that reason.
Incorrect: Glucagon is a hormone used to raise blood sugar and manage severe hypoglycemia.
Clients with gestational diabetes have hyperglycemia.
Correct: Insulin is the drug of choice for gestational diabetes. Insulin lowers the client's
blood sugar without harming the fetus.
Incorrect: DiaBeta is an oral hypoglycemic drug. Oral hypoglycemic agents cross the placenta
and can cause damage to the fetus. They are not used for gestational diabetes for that reason.
Metformin (Glucophage)
Glucagon
Insulin
Glyburide (DiaBeta)
11. Which assessment finding indicates that placental separation has occurred during the
third stage of labor?
Incorrect: There is usually an increase in bleeding (a sudden gush of blood) when the placenta
separates.
Incorrect: Contractions continue in an attempt to expel the placenta. The contractions may not
be as intense, but they do not stop. Also, fundal massage helps contract the uterus preventing
postpartum bleeding.
Incorrect: Shaking and chills occur about 10-15 minutes after the delivery of the baby, but are
not related to the placental detachment. They are a result of the release of pressure on pelvic
nerves and the release of epinephrine during labor.
Correct: As the placenta detaches, the cord that has been clamped becomes longer as it
slides out of the vagina.
Decreased vaginal bleeding
Contractions stop
Maternal shaking and chills
Lengthening of the umbilical cord
12. The nurse midwife is concerned about a pregnant client who is suspected of having a
TORCH infection. Which is the main reason TORCH infections are grouped together? They
are:
Incorrect: Most TORCH infections can cause mild flu-like symptoms for the mother. Death may
or may not occur in the fetus.
Incorrect: TORCH is an abbreviation for Toxoplasmosis, Other (syphilis, HIV and Hepatitis B),
Rubella, Cytomegalovirus, and Herpes simplex—not all of these are sexually transmitted.
Correct: All TORCH infections have the capability of infecting the fetus or causing serious
effects to the newborn.
Incorrect: A vector is a carrier of the disease such as a mosquito. Not all of the TORCH
infections are carried by vector.
benign to the woman but cause death to the fetus.
sexually transmitted.
capable of infecting the fetus.
transmitted to the pregnant woman by a vector.
13. During the postpartum period, a hospitalized client complains of discomfort related to her
episiotomy. The nurse assigns the diagnosis of “pain related to perineal sutures.” Which
nursing intervention is most appropriate during the first 24 hours following an episiotomy?
Incorrect: Petroleum jelly will harbor bacteria, which may hinder healing.
Incorrect: The client should practice Kegel exercises to increase bladder tone, but these exercises
would add to the client's discomfort during the first 24hours.Incorrect: Taking a warm sitz bath
is recommended after the first 24 hours.
Correct: Ice packs will decrease edema and discomfort, and prevent formation of a
hematoma.
Instruct the client to use petroleum jelly on the episiotomy after voiding.
Encourage the client to practice Kegel exercises.
Advise the client to take a warm sitz bath every four hours.
Apply ice packs to the perineum.
14. A client asks the nurse about the benefits of breastfeeding. Which response by the
nurse provides the most accurate information?
Incorrect: Breastfeeding does not help speed up weight loss. The lactating mother requires more
calories, but usually has an increased appetite to accommodate that need.
Incorrect: Protein amounts are greater in formula and cow's milk.
Correct: Breast milk is easier to digest because of the type of fat and protein in the milk.
Incorrect: Breastfeeding does not prevent to woman from getting pregnant because it does not
prevent ovulation. Most women ovulate within the first 6 weeks after delivery.
Breastfeeding helps women lose weight faster.
Breast milk contains a greater amount of protein.
Breast milk is easier to digest than formula.
Breastfeeding is a good method of contraception.
15. Which physiological change takes place during the puerperium?
Incorrect: The puerperium is the first 6 weeks after delivery. The client will experience lochia
for the first few weeks, and hormone levels will stabilize. Menstruation cannot occur until
ovulation occurs.
Incorrect: This occurs in stage three of labor.
Correct: The uterine changes are called involution. The uterus should return to its pre-
pregnancy state within 6 weeks after delivery.
Incorrect: This describes the labor process, not the puerperium.
The endometrium begins to undergo alterations necessary for menstruation.
The placenta begins to separate from the uterine wall.
The uterus returns to a pre-pregnant size and location.
The uterus contracts at regular intervals with dilation of the cervix occurring.
16. A client delivered two days ago and is suspected of having postpartum "blues."
Which symptoms confirm the diagnosis?
Correct: These are signs of the postpartum blues, which typically diminishes within three-
four days after delivery. Postpartum blues, a transient period of tearfulness, is a result of
hormonal shifts. Other symptoms of the blues include: sadness, anxiety about the health of
the baby, insomnia, anorexia, anger, feelings of anticlimax.
Incorrect: Postpartum blues, a transient period of tearfulness, is a result of hormonal shifts.
Depression and suicidal thoughts are signs of postpartum depression, not the blues and should be
followed up with psychiatric treatment.
Incorrect: Excess anxiety and the inability to care for the family are signs of postpartum
depression, not the blues. Postpartum blues, a transient period of tearfulness, is a result of
hormonal shifts.
Incorrect: Nausea and vomiting are psychosomatic symptoms of postpartum depression and
require psychiatric treatment. Postpartum blues, a transient period of tearfulness, is a result of
hormonal shifts.
Uncontrollable crying and insecurity
Depression and suicidal thoughts
Sense of the inability to care for the family and extreme anxiety
Nausea and vomiting
17. Shortly after delivery, the nursery nurse gives the newborn an injection of
phytonadione (Vitamin K). The infant's grandmother wants to know why the baby got “a
shot in his leg.” Which response by the nurse is most appropriate?
Incorrect: Calcium is needed for bone and muscle growth, not Vitamin K.
Incorrect: Vitamin K is used to promote clotting, and does not affect digestion.
Incorrect: The B vitamins are responsible for carbohydrate metabolism and the energy derived
from glucose, not Vitamin K.
Correct: Vitamin K is given to prevent bleeding until the intestinal bacteria can start to
produce it. The intestines of a newborn are sterile until it starts to feed. Vitamin K
helps with the clotting factors necessary to control bleeding.
"Vitamin K promotes bone and muscle
growth." "Vitamin K helps the baby digest
milk."
"Vitamin K helps stabilize the baby's blood sugar."
"Vitamin K is used to prevent bleeding."
18. At 10 weeks gestation, a primigravida asks the nurse what is occurring developmentally
with her baby. Which response by the nurse is correct?
Incorrect: Wrinkles do not form until late in the pregnancy. Fat stores usually do not form until
the third trimester.
Incorrect: The eyelids are fused until about 26 weeks.
Correct: The kidneys are making urine, which is excreted by the fetus into the amniotic
fluid.
Incorrect: The heart is already formed and beating at 8 weeks.
"The skin is wrinkled and fat is being formed."
"The eyelids are open and he can see."
"The kidneys are making urine."
"The heart is being developed."
19. A nurse in the clinic instructs a primigravida about the danger signs of pregnancy. The client
demonstrates understanding of the instructions, stating she will notify the physician if which sign
occurs?
Incorrect: White vaginal discharge is a normal occurrence during pregnancy due to increased
amounts of estrogen and increased blood supply to the cervix and vagina. It is not a “danger sign.
“
Incorrect: Backache is common in pregnancy due to the alteration of the woman's center of
gravity; it is not a “danger sign.” Backaches become worse as the uterus enlarges.
Incorrect: Frequent, urgent urination is a common discomfort; it is not a danger sign. The
pressure of the enlarging uterus causes frequency and urgency.
Correct: Abdominal pain is a danger sign and can be indicative of an abruptio placenta. It
is important for a physician to evaluate this symptom. It is one of several danger signs,
including: headache, rupture of membranes, vaginal bleeding, edema, epigastric pain,
elevated temperature, painful urination, prolonged vomiting, blurred vision, change in or
absence of fetal movement.
White vaginal discharge
Dull backache
Frequent, urgent urination
Abdominal pain
20. An hour after delivery, the nurse instills erythromycin (Ilotycin) ointment into the eyes of a
newborn. The main objective of the treatment is to prevent infection caused by which
organism?
Incorrect: Erythromycin (Ilotycin) is an antibiotic ointment used to prevent blindness related to
gonorrhea. Antibiotics are effective against bacteria. Rubella is a virus.
Correct: Ilotycin, an antibiotic, is used for the prophylaxis treatment of gonorrhea and
chlamydia. If left untreated, it could result in blindness.
Incorrect: Ilotycin, an antibiotic, is not effective in combating syphilis infections.
Incorrect: HIV is a virus. Antibiotics are effective against bacteria. Ilotycinis an antibiotic
ointment and therefore not effective against HIV.
Rubella
Gonorrhea
Syphilis
Human immunodeficiency virus (HIV)
21. A woman in active labor receives a narcotic analgesic for pain control. If the narcotic is
given a half an hour before delivery, which effect will the medication have on the infant? It will
cause the infant's:
Incorrect: Narcotic analgesics cause respiratory depression and do not affect the infant's blood
sugar.
Correct: Narcotic analgesics can cause respiratory depression for the infant and also for
the mother. This is evidenced by low Apgar scores (apnea and bradycardia) in the infant.
If respiratory depression occurs, a narcotic antagonist (Narcan) is usually given.
Incorrect: Narcotic analgesics, if given too close to delivery, can cause bradycardia, not
tachycardia.
Incorrect: Narcotics, such as Demerol, cause CNS depression, not hyperactivity.
blood sugar to fall.
respiratory rate to decrease.
heart rate to increase.
movements to be hyperactive.
22. For a client in the second trimester of pregnancy, which assessment data support a
diagnosis of pregnancy-induced hypertension (PIH)?
Incorrect: A decrease in hemoglobin is indicative of anemia, while uterine tenderness may
indicate abruptio placenta.
Incorrect: Polyuria and weight loss are signs of gestational diabetes.
Correct: PIH is characterized by two components: elevated blood pressure and
proteinuria. Vasospasm in the arterioles leads to increased blood pressure and a decrease
in blood flow to the uterus and placenta. This results in a questionable outcome for the
fetus due to placental insufficiency. Renal blood flow is affected, ultimately resulting in
proteinuria.
Incorrect: Elevated blood glucose is a sign of gestational diabetes. Hematuria may indicate a
U.T.I.
Hemoglobin 10.2 mg/dL and uterine tenderness
Polyuria and weight loss of 3 pounds in the last month
Blood pressure 168/110 and 3+ proteinuria
Hematuria and blood glucose of 160 mg/dL
23. A 35-week gestation infant was delivered by forceps. Which assessment findings should
alert the nurse to a possible complication of the forceps delivery?
Correct: A weak, ineffective suck could be a result of facial paralysis which is a major
complication of forceps deliveries. Scalp edema is another complication and should subside
within 2-3 days. Other complications of forceps deliveries include: cephalohematomas,
intracranial hemorrhage (especially in premature infants) and excessive bruising, which
increases the risk for hyperbilirubinemia.
Incorrect: Molding of the head is a common occurrence with vaginal deliveries. Jitteriness is a
sign of low blood sugar, not forceps delivery.
Incorrect: A shrill, high-pitched cry and tachypnea are signs of drug withdrawal, not a
complication of forceps delivery.
Incorrect: Hypothermia is not a complication of forceps deliveries. The hemoglobin level is
quite low (should be about 15-16 g/dL), but unless there is excessive bleeding, the hemoglobin
level should be unaffected by the forceps delivery.
Weak, ineffective suck, and scalp
edema Molding of the head and
jitteriness Shrill, high pitched cry, and
tachypnea
Hypothermia and hemoglobin of 12.5 g/dL
24. In which position should the nurse place the laboring client in order to increase the intensity
of the contractions and improve oxygenation to the fetus?
Incorrect: This position is contraindicated because the fetus creates pressure on the mother's vena
cava. Incorrect: Squatting widens the pelvic inlet, but does not improve contractions or fetal
oxygenation.
Correct: This prevents vena cava compression and, therefore, improves fetal oxygenation;
at the same time, it provides a restful position between contractions.
Incorrect: High Fowler's (sitting upright) will assist with the intensity of the contractions
because of gravity, but it will not help with fetal oxygenation.
Supine with legs elevated
Squatting
Left side-lying
High Fowler's
25. A woman enters the birthing center in active labor. She tells the nurse that her
membranes ruptured 26 hours ago. The nurse immediately takes the client's vital signs.
Which is the rationale for the nurse's actions?
Incorrect: Pulse rates increase due to pain, not because of rupture of membranes.
Incorrect: The woman is not reporting pain and ruptured membranes do not cause pain. Lack of
fluid (ruptured membranes) has no influence on respiratory rates.
Incorrect: Blood pressure is not affected by prolonged rupture of membranes.
Correct: The membranes are a protective barrier for the fetus. If the membranes are
ruptured for a prolonged period of time, microorganisms from the vagina can ascend into
the uterus. The longer the membranes have been ruptured, the greater the risk for
infection.
Pulse rates rise the longer the membranes are ruptured
Respiratory rates decrease due to lack of fluid in the uterus
Prolonged rupture of membranes can lead to transient hypertension
Infection is a complication of prolonged rupture of membranes
26. A new client's pregnancy is confirmed at 10 weeks gestation. Her history reveals that her
first two pregnancies ended in spontaneous abortion at 12 and 20 weeks. She has a4-year-old
and a set of 1-year-old twins. How should the nurse record the client's current gravida and para
status?
Incorrect: Gravida includes the number of times the woman has been pregnant. She has been
pregnant 5 times. A parity of 3 would be obtained by incorrectly counting the 20-week
spontaneous abortion as a viable infant.
Incorrect: The woman has been pregnant 5 times, including the present pregnancy. The abortions
count as pregnancies, but not in the parity.
Correct: Gravida is the number of times a woman has been pregnant, including the present
pregnancy. Para is the number of pregnancies carried past 20 weeks' gestation, regardless
of the number of fetuses delivered. The woman has been pregnant five times, including this
pregnancy, and has had two pregnancies that have exceeded 20 weeks. Even though she
delivered two children as a result of one of those pregnancies, the para for her twin
pregnancy remains at 1. The pregnancy after which she delivered her four-year-old child
makes her a para 2.
Incorrect: A para of 4 would be obtained by incorrectly counting the 2 spontaneous abortions as
viable at delivery.
Gravida 2, para 3
Gravida 4, para 2
Gravida 5, para 2
Gravida 5, para 4
27. A 16-year-old client reports to the school nurse because of nausea and vomiting. After
exploring the signs and symptoms with the client, the nurse asks the girl whether she could be
pregnant. The girl confirms that she is pregnant, but states that she does not know how it
happened. Which nursing diagnosis is most important?
Incorrect: Although this addresses the client's nausea and vomiting, it is not the most important
diagnosis at this time. There are no data to indicate that the client actually has a nutritional
deficit. Because nausea and vomiting place her at risk for nutritional deficit, a diagnosis of “risk
for altered nutrition. . .” would be appropriate. The knowledge diagnosis is an actual problem
and should be addressed at this contact with the client; the nutrition problem will be ongoing
during the pregnancy.
Incorrect: This diagnosis does not address the reason for the lack of client knowledge—she may
be at risk for poor parenting, but this is not the priority because there will be time to address that
issue as the pregnancy progresses.
Incorrect: There is no clear evidence of the denial of pregnancy nor of the lack of coping skills.
Correct: This client clearly has a knowledge deficit about the causes of pregnancy and
the physiological changes associated with it. It is important for teaching to begin
immediately because her understandings essential to her compliance with suggestions for
a healthy pregnancy.
Altered nutrition: less than body requirements related to nausea and vomiting
Risk for altered family processes related to the client's age
Ineffective individual coping related to denial of pregnancy
Knowledge deficit related to the client's developmental stage and age
28. A client is admitted to the hospital for induction of labor. Which are the main indications
for labor induction?
Incorrect: These are contraindications for labor induction.
Correct: Induction of labor is the stimulation of contractions (usually by the use of Pitocin)
before they begin on their own. Maternal indications for induction of labor include:
pregnancy induced hypertension, chorioamnionitis, gestational diabetes, chronic
hypertension and premature rupture of membranes. Fetal indications include intrauterine
growth retardation, post-term dates and fetal demise.
Incorrect: These are contraindications for labor induction.
Incorrect: These are contraindications for labor induction. They are indications for a C-section.
Placenta previa and twins
Pregnancy-induced hypertension and postterm fetus
Breech position and prematurity
Cephalopelvic disproportion and fetal distress
29. A client in active labor receives a regional anesthetic. Which is the main purpose of
regional anesthetics?
Incorrect: This choice describes general anesthesia.
Correct: Regional anesthetics provide numbness and loss of pain sensation to an area. The
most common regional blocks are: local, pudendal, epidural, and spinal.
Incorrect: Pain sensations travel to the central nervous system not away from it.
Incorrect: This choice describes the action for narcotic medications, not regional anesthetics.
To relieve pain by decreasing the client's level of consciousness
To provide general loss of sensation by blocking sensory nerves to an area
To provide pain relief by blocking descending impulses from the central nervous system
To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
30. The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5
at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these
scores? The infant:
Incorrect: Usually babies that only need suctioning of the mouth and nose have Apgars that are 8
or 9.
Incorrect: If intubation is required, it means that the baby's heart and respiratory rates are not
stable, and Apgars would be lower than 5.
Incorrect: Apgar scores are used to quickly assess the well-being of the baby. Apgar scores
range from 0-10. A score of 0 indicates that the baby is dead. An Apgar score of 5 indicates that
the baby needs assistance.
Correct: Apgar scores of 5 and 7 indicate that the heart rate was below 100, the respiratory
effort was irregular, there was little muscle tone, the baby was pink with blue extremities,
and there was a grimace. These scores indicate that the baby needed stimulation in order to
breathe, and oxygen to increase its oxygen saturation.
needed brief oral and nasal suctioning.
required endotracheal intubation and bagging with a hand-held resuscitator.
was stillborn and required CPR.
required physical stimulation and supplemental oxygen.
31. With routine prenatal screening, a woman in the second trimester of pregnancy is
confirmed to have gestational diabetes. How may the nurse explain the role of diet and insulin
in the management of blood sugar during pregnancy?
Correct: Insulin is given to gestational diabetic clients because their insulin requirements
cannot keep up with the metabolic needs of the fetus in the last trimester. Insulin decreases
the blood sugar.
Incorrect: Oral hypoglycemic agents are not given to clients with gestational diabetes because
they cross the placenta and are harmful to the fetus.
Incorrect: The client will need frequent follow-up after delivery and into the postpartum period,
but she should not need insulin after delivery because in gestational diabetes, blood glucose
usually returns to normal after delivery.
Incorrect: Clients with gestational diabetes need to eat three balanced meals and three snacks
daily. The glucose load is best when maintained at a steady level throughout the day to avoid
periodic overproduction of insulin. The last snack of the day should contain protein to stabilize
the energy production during the night.
"Insulin lowers an elevated blood sugar during pregnancy to meet the increased metabolic needs
of the baby."
"You will need to take an oral hypoglycemic, which is a pill to lower your blood sugar."
"There is a good possibility you will be taking insulin for the rest of your life."
"You should eat three large meals per day to maintain steady glucose load."
32. A breastfeeding mother complains of cramping. Which is the main cause of the
client's afterpains?
Incorrect: Infection of the suture line can cause pain and discomfort, but is not the cause of
afterpains. Afterpains are postpartum uterine contractions.
Incorrect: Constipation and bloating do occur in the postpartum period as peristalsis resumes, but
constipation does not cause afterpains, which are uterine contractions.
Correct: Afterpains are caused by uterine contractions that occur for the first 2-3 days
postpartum. Breast-feeding mothers have more afterpains due to the release of oxytocin
stimulated by the nursing baby. Oxytocin strengthens uterine contractions and compresses
blood vessels, preventing blood loss.
Incorrect: Trauma is not the cause of afterpains. Afterpains are postpartum uterine contractions.
Infection of the suture line
Constipation and bloating
Contractions of the uterus
Trauma during delivery
33. A client who is 37 weeks gestation comes to the office for a routine visit. This is the
client's first baby and she asks the nurse how she will know when labor begins. Which signs
indicate that true labor has begun?
Incorrect: These signs describe Braxton-Hicks contractions, which occur throughout pregnancy
and increase in intensity and frequency as labor grows closer.
Incorrect: True labor pains start in the lower back and sweep to the front in waves.
Incorrect: These signs occur with lightening, usually 10-14 days before labor begins.
Correct: These are true signs of labor, along with the rupturing of the membranes and
cervical dilatation.
Contractions that are irregular and decrease in intensity when walking
Abdominal pain that starts at the fundus and progresses to the lower back
Increased pressure on the bladder and urinary frequency
Expulsion of pink-tinged mucous and contractions that start in the lower back
34. A multiparous woman with a history of all vaginal births is admitted to the hospital in
labor. After several hours, the client's labor has not progressed and she is getting tired and
restless. The decision is made to proceed with cesarean delivery. The nurse recognizes the
client's knowledge deficit regarding the surgical delivery and care afterbirth. Which is the
appropriate expected outcome for correction of the client's knowledge deficit? The client will:
Incorrect: This expected outcome does not address the client's knowledge deficit. Instead, this is
an expected outcome for the nursing diagnosis of ineffective individual coping.
Incorrect: This choice does not address the client's knowledge deficit, but instead addresses a
problem with interrupted bonding.
Correct: Goals/outcomes should reflect resolution of the stated nursing diagnosis—in this
case, knowledge deficit. Verbalization of reasons for the surgery would indicate resolution
of the knowledge deficit. If interventions for knowledge deficit are effective, other problems
(e.g., anxiety, ineffective coping) may be prevented.
Incorrect: This choice addresses the anxiety that will occur because of the unknown, but does not
address the stated problem, knowledge deficit.
demonstrate appropriate coping mechanisms needed to get through the
surgery. accept that the type of delivery will not affect the bonding with the
baby. verbalize understanding about the reason for the unplanned surgery.
demonstrate decreased anxiety and fear of the unknown.
35. The physician performs an amniotomy for a woman in labor. Which nursing action
should follow the procedure?
Incorrect: Maternal oxygenation is not affected by an amniotomy.
Incorrect: Maternal pulse and blood pressure are not affected by an amniotomy.
Incorrect: Assessing the perineum should be done after an episiotomy, not after amniotomy.
Correct: An amniotomy, or artificial rupture of membranes (AROM), is used to speed up
labor. The nurse must document the color, amount, character and odor of the fluid, and
assess for fetal well being.
Check the client's capillary refill and oxygenation.
Monitor the maternal pulse and blood pressure.
Inspect the perineum for lacerations, bleeding, and hematoma.
Assess the fluid for color, odor, and amount.
36. For a pregnant adolescent who is anemic, which foods should the nurse include In the
client's dietary plan to increase iron levels?
Incorrect: Milk does not contain iron and it interferes with iron absorption.
Correct: Orange juice enhances the absorption of iron. Apricots are a good source of iron.
Incorrect: Chicken does contain iron, but cottage cheese, a dairy product, does not.
Incorrect: Pickles contain large amounts of salt, not iron. Peanut butter sandwiches do not
contain much iron.
Milk and fish
Orange juice and apricots
Chicken and cottage cheese
Pickles and peanut butter sandwiches
37. Which condition must occur in order for identical (monozygotic) twins to develop?
Incorrect: Usually only one ovum is released per month; one sperm cannot fertilize two ova.
Incorrect: This is the case in fraternal (dizygotic) twins. There are two placentas, two chorions,
and two amnions. The twins may be the same or different sex.
Correct: One sperm fertilizes one ovum, and then the zygote divides into two individuals
with one placenta, one chorion, two amnion and two umbilical cords. These twins are
always the same sex.
Incorrect: The enzyme on the head of the sperm dissolves the coating of the ovum so eventually
only one sperm penetrates one egg.
One sperm fertilizes two ova
Two sperm fertilize two ova
One sperm fertilizes one ovum
Two sperm fertilize one ovum
38. Which fetal structure is responsible for carrying oxygenated blood from the placenta to
the fetus?
Incorrect: The ductus arteriosus is a shunt that connects the lungs to the aorta, allowing the blood
to bypass the lungs.
Incorrect: Except in the case of fetal circulation, arteries do carry oxygenated blood; but during
pregnancy, the two umbilical arteries carry unoxygenated blood from the fetus to the placenta,
where preoxygenation occurs. Incorrect: The portal vein carries blood from the intestine to the
liver.
Correct: The umbilical vein carries oxygenated blood from the placenta to the fetus. The
direction of blood flow is toward the fetal heart.
Ductus arteriosus
Umbilical artery
Portal vein
Umbilical vein
39. A client at 33 weeks gestation is admitted for suspected abruptio placenta. Which factor
in the client's history supports this diagnosis? The client states that she:
Incorrect: Drinking alcohol is not usually associated with abruptio placenta. Incorrect: Clients
with abruptio placenta do not have contractions that can be relieved by walking. Usually the pain
is quite intense.
Incorrect: Intercourse should not cause an abruptio placenta, although it is contraindicated in
clients with placenta previa.
Correct: The use of crack cocaine is associated with the separation of the placenta and the
bleeding/ hemorrhage that results. Cocaine use is not usually an isolated incident, so the
nurse should ask the client about the frequency/amount of the drug usage.
drinks two glasses of wine before dinner every night.
has intermittent contractions that are relieved by walking.
had intercourse with her partner last night.
used crack an hour before the symptoms began.
40. Which explanation is most appropriate when describing physiological jaundice to the
parents of a newborn?
Incorrect: Pathological jaundice, not physiological jaundice, occurs within the first 24 hours and
is a result of an ABO incompatibility or Rh incompatibility.
Correct: Physiological jaundice is the result of the breakdown of excessive amounts of red
blood cells that are not needed after birth. Physiological jaundice is also related to the
inability of the immature liver to rid the body of bilirubin, which occurs as the red blood
cells are broken down. The bilirubin accumulates in the blood causing it to be yellow.
Incorrect: Jaundice related to breast milk occurs after the first 7 days, not within the first three. It
is not the cause of physiological jaundice.
Incorrect: Hepatitis B may have been acquired during delivery and may cause jaundice, but it is
not the cause of physiological jaundice, which this case represents.
"The baby has a minor incompatibility of the blood."
“The baby is breaking down the extra red blood cells that were present at birth.”
“The baby is getting too much breast milk, but this is not dangerous.”
“The baby may have gotten exposed to hepatitis B during the delivery.”
41. A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant
is postterm, which complications should the nurse anticipate when planning for the delivery?
Incorrect: Cephalopelvic disproportion is seen in large-for-gestational age infants, not postterm
infants. Hypothermia occurs in premature and small-for-gestational age infants.
Correct: Asphyxia is a result of chronic hypoxia in utero because of the progressive
degeneration of the placenta. Meconium stained amniotic fluid is a result of the relaxation
of the anal sphincter and the passage of meconium into the fluid related to hypoxia. If the
meconium stained fluid is aspirated into the infant's lungs at delivery, pneumonia (and
possibly death) will result. If there is meconium stained fluid, the infant's mouth and
throat are suctioned as soon as the head is delivered.
Incorrect: Intraventricular hemorrhage occurs as a major complication in premature infants, not
postterm infants. Dry, cracked skin is a normal finding of postterm infants and is not considered
a complication.
Incorrect: Hyperbilirubinemia is not a complication of postterm infants at birth. Hypocalcemia is
a complication in small-for gestational age infants
Cephalopelvic disproportion and hypothermia
Asphyxia and meconium aspiration
Intraventricular hemorrhage and dry, cracked
skin Hyperbilirubinemia and hypocalcemia
42. Which method of temperature regulation would safely and effectively prevent cold stress in
a newly delivered infant?
Incorrect: The baby should be wrapped snuggly with a warm blanket in order to preserve heat
loss.
Incorrect: It helps to cover the feet, of course. However, because the scalp is so vascular (and the
blood is close to the surface) and because the head makes up a large portion of the baby's surface
area, most heat loss occurs via the head initially. Peripheral circulation is sluggish at first, so not
much blood would be cooled by circulating through cold feet.
Correct: Newly delivered infants lose a great deal of heat as the amniotic fluid evaporates
from the surface of the skin. To prevent rapid heat loss, the baby's face and head should be
dried and a hat placed on the baby's head.
Incorrect: Infants should NEVER be placed on a heating pad because of risk for burns.
Wrap the baby loosely with a
blanket. Be sure the baby's feet are
covered.
Cover the baby's head with a hat.
Position the baby on a heating pad.
43. The nurse performs Leopold's maneuvers for a client admitted in labor. Which is the
main goal of Leopold's maneuvers?
Incorrect: Sterile vaginal exams are used to assess the dilation of the cervix.
Incorrect: Leopold's maneuvers are not used to assess contraction frequency or intensity.
However, some nurses do place their hands on the abdomen to palpate the intensity and
frequency of the contractions.
Incorrect: Leopold's maneuvers are not used to assess membrane rupture. Sterile vaginal exams
may assess this if membranes are intact.
Correct: Leopold's maneuvers are a method of determining fetal position by abdominal
palpation. It assesses the position, presentation and engagement of the fetus. It also assists
in the location of fetal heart sounds.
To determine whether the client's cervix has dilated
To assess the frequency and intensity of the
contractions To assess whether membranes have been
ruptured
To determine the presentation and position of the fetus
44. Immediately after birth, the nurse places the newborn under a radiant warmer. Which is
the primary rationale for the nurse's action?
Correct: Temperature regulation is the priority for the newborn. Infants who are cold
stressed are at risk for respiratory complications or death.
Incorrect: Placing the infant in the warmer does assist the nurse with easier access, but
temperature regulation is the main priority.
Incorrect: Most infants are not connected to the cardiac monitor unless the Apgar scores are low.
Incorrect: The warmer does provide easy access for the family, but this is not the main reason for
its use.
To facilitate an efficient means of
thermoregulation To facilitate initial assessment by
the nurse
To permit the use of the cardiac monitor
To permit close observation by the family members
45. A client, gravida 1, para 0, in active labor, is becoming increasingly anxious.
Which statement by the nurse will block therapeutic communication with the client?
Incorrect: Since this is the client's first baby, there will be concerns/anxiety because of the
unknown expectations. This response is appropriate, and will help decrease anxiety by allowing
identification and ventilation of fears.
Incorrect: This response will encourage the client to talk and will foster good communication.
Correct: This is an example of meaningless reassurance and will block therapeutic
communication because the needs of the client are not being met.
Incorrect: This response will facilitate communication, not block
it. "What concerns are you having now?"
"Tell me how you are feeling."
"Everything is going just fine."
"You seem a little nervous."
46. A nurse prepares to teach a class regarding postpartum care and includes infections in
the teaching plan. Which is the main cause of mastitis in the postpartum client?
Correct: Poor breast-feeding technique and improper positioning of the baby are the main
reasons for mastitis. Improper release of the baby's suction can lead to sore, cracked
nipples, creating a portal of entry for pathogens.
Incorrect: Poor hand washing is not the main reason that a woman gets mastitis but can be a
contributing cause. For example, if the woman touches her perineal pad and then the breast, the
bacteria on the hands can cause an infection.
Incorrect: Systemic infections such as flu or cold are not the cause of mastitis, which is a
localized infection.
Incorrect: Prolonged nursing by itself does not cause mastitis. Often babies engage in
nonnutritive sucking.
Poor breast feeding technique
Inadequate hand washing
Systemic maternal infection
Prolonged nursing
47. A postterm infant is delivered by cesarean section because of fetal distress and
meconium- stained amniotic fluid. The nursery nurse frequently monitors the baby's
respiratory rate, observing for tachypnea. Which is the reason for the nurse's actions? The
infant may:
Incorrect: Respiratory depression does not result in tachypnea but in apnea.
Correct: This infant is a risk for meconium aspiration pneumonia related to post maturity,
meconium staining, fetal distress and being delivered by c-section.
Incorrect: Infants with respiratory distress (tachypneic) are usually cold stressed and
hypothermic, not hyperthermic.
Incorrect: A pneumothorax usually is seen in premature infants who lack surfactant.
experience respiratory depression from the medications used during delivery.
develop meconium aspiration pneumonia.
have an elevated temperature.
have a pneumothorax related to delivery.
48. The nurse notices a variable deceleration on a fetal monitor strip. Which nursing action
is appropriate?
Incorrect: Hyperventilation is not the cause of the variable decelerations.
Incorrect: Hypertonic uterine contractions refer to a labor with very painful but not necessarily
effective contractions. The uterus does not relax between contractions. This leads to fetal distress
and results in late decelerations, not variable decelerations.
Correct: Variable decelerations are a result of cord compression. Turning the client onto
her left side may improve fetal oxygenation by relieving pressure on the cord.
Incorrect: Variable decelerations are a result of fetal cord compression. Decreasing the fluids
will not relieve cord compression.
Instruct the mother to breathe slowly because this is a sign of hyperventilation.
Decrease the amount of Pitocin because this is a sign of hypertonic uterine contractions.
Turn the woman onto her left side to relieve pressure on the umbilical cord.
Reduce the oral and IV fluids to decrease circulatory overload.
49. The nursery nurse delays the first bottle feeding of a newborn. Which is the most
common reason for the nurse's actions? The infant has:
Incorrect: One method of increasing an infant's low blood sugar is by feeding him.
Correct: Bottle feeding of an infant who is tachypneic (resp. rate > 60) is contraindicated
due to risk of aspiration.
Incorrect: Acrocyanosis (blue hands and feet) is a normal finding for the first 24 hours.
Incorrect: It is not unusual for the nurse to hear a heart murmur shortly after birth.
a blood glucose of 45 gm/dL.
a respiratory rate above
60. blue hands and feet.
a heart murmur.
50. During active labor, after a sudden slowing of the fetal heart rate, the nurse assesses the
woman's perineum and observes a prolapsed cord. Which nursing action is most
appropriate?
Correct: With a sterile gloved hand, the nurse should push the presenting part away from
the cord, thus preventing cord compression. The cord supplies the fetus with oxygen and
nutrients. The fetus is already showing signs of distress because of the slowing of the
heart rate. In addition, the nurse should prepare for immediate delivery.
Incorrect: Since the head is not engaged (which is why the cord prolapsed), it will be very
difficult to insert a scalp electrode.
Incorrect: Trendelenburg position places the client with her head lower than her feet. Reverse
Trendelenburg places the client with the head higher than the feet. Due to gravity, this will place
additional pressure on the cord.
Incorrect: Covering the cord with a dry gauze will not help the situation. The gauze will get wet
in a matter of seconds. There is a risk that the gauze will be lost internally.
Hold the presenting part away from the cord.
Insert a scalp electrode for an internal fetal
monitor. Place the client in reverse Trendelenburg
position. Cover the cord with a dry, sterile gauze.
51. A client is in the latent stage of labor. Which nursing intervention is most appropriate?
Correct: Latent stage is an early stage of labor, which begins with the onset of contractions
and ends when the cervix is dilated to 4 cm. Walking adds gravity to the force of the
contractions, promotes fetal descent, and relieves backache. Once the membranes rupture,
bed rest may be indicated, for example if the fetal head is not engaged.
Incorrect: Pushing is not indicated until full cervical dilation.
Incorrect: This type of breathing pattern is used late in labor when pushing begins.
Incorrect: Once labor begins fluids and ice chips are preferred. Nausea and vomiting are
common as labor progresses. During labor, peristalsis stops. Therefore, having food in the
stomach is not advisable.
Encourage the client to walk in the hall until membranes rupture.
Instruct the client to place her head on her chest and push with the contraction.
Teach the client to use the “pant-blow” method of breathing.
Advise the client to eat a light meal consisting of carbohydrates.
52. Which conditions create a risk for uterine atony in the immediate postpartum period?
Incorrect: Breastfeeding causes uterine contractions due to the release of oxytocin. Uterine atony
is not related to the delivery of a child with chromosomal defect.
Incorrect: Uterine atony is not a result of postterm pregnancy or amniotomy.
Incorrect: Gestational diabetes in and of itself does not cause uterine atony. However, clients
with gestational diabetes do have babies that are large for gestational age (> 4000 grams).
Pregnancy-induced hypertension is associated with vasospasm, which does not result in uterine
atony.
Correct: Uterine atony is the inability of the uterus to contract, which leads to hemorrhage.
Clients who have had more than one delivery have decreased muscle tone in the uterus.
Clients with twins or triplets are at risk for overdistention of the uterus, which may lead to
uterine atony and hemorrhage.
Breast feeding and delivery of an infant with chromosome defects
Postterm birth and an amniotomy during labor
Gestational diabetes and pregnancy-induced hypertension
Multiparity and multiple gestation
53. A client at ten weeks gestation tells the nurse that she has been having “morning
sickness.” The nurse advises the client to eat foods that are easy to digest and low in fat.
Which is the rationale for the nurse's instruction?
Incorrect: Low fat diets do not stimulate peristalsis. On the contrary, high fat foods can lead to
bloating, increased peristalsis and diarrhea.
Correct: Foods containing a high fat content stay in the digestive system longer. Decreasing
the amount of fat causes faster gastric emptying, which leaves less in the stomach to be
vomited. Incorrect: Fluid and electrolyte imbalance is not a cause of nausea and vomiting
related to pregnancy.
Incorrect: Relaxation of the cardiac sphincter, causing heartburn, is a result of increased
progesterone. It causes heartburn, not nausea and vomiting.
A low-fat diet increases peristalsis, which reduces the food volume in the stomach
A low-fat diet is digested faster and leaves less in the stomach that can be vomited
Easily digested foods provide a better balance of fluids and electrolytes, resulting in less nausea
and vomiting
Easily digested foods are less likely to cause relaxation of the cardiac sphincter, which causes
regurgitation and vomiting
54. Which information is most important for the nurse to gather when a client is admitted to
the unit in labor?
Incorrect: This is useful information, but the priority information is that regarding medical
conditions which may create serious risks to the fetus and mother.
Correct: Asking the client about any medical problems should be the priority because it
provides a quick assessment for risks to the fetus and mother.
Incorrect: Fluids are given in the latent phases of labor, but gathering this information at the
initial admission interview is not as important as obtaining information about medical conditions
which may create serious risks to the fetus and mother.
Incorrect: This is not important unless the client has PIH or a cardiac condition. Even then, the
initial assessment would be to find out if the client actually has PIH or cardiac condition (e.g., by
checking the history), not to diagnose it.
Name of the support person
Medical problems or complications
Fluid preferences
Amount of weight gained during the pregnancy
55. The nurse conducting a physical assessment notes that a 1-day-old newborn with dark skin
has a bluish-gray discoloration over the lower back, the buttocks, and the scrotum. How should
this assessment finding be documented?
Incorrect: Bruising usually does not involve the scrotum, and is not usually gray.
Correct: Mongolian spots are the result of increased pigmentation over parts of the baby.
They are most commonly found in infants of Asian, Indian, African-American or
Mediterranean descent. They are harmless and fade during the first two years of life.
Incorrect: Nevus flammeus is a dark red lesion called a port wine stain. It does not blanch when
touched, and does not fade with age. This type of hemangioma usually is seen on the face or
thigh rather than the back.
Incorrect: Acrocyanosis, a normal finding, is a bluish discoloration of the hands and feet (not the
back or buttocks), and is related to sluggishness of the peripheral circulation.
Extensive bruising
Mongolian spots
Nevus flammeus
Acrocyanosis
56. A small-for-gestational-age infant is irritable and jittery, and has hyperreflexia and clonus.
He is jaundiced, has temperature instability, and spitty after feedings. The nurse suspects the
infant is displaying signs of passive addiction during pregnancy. When planning for the infant's
care at home, which nursing assessment is most important for the infant experiencing neonatal
abstinence syndrome?
Correct: In cases of maternal drug addiction, it is very important that the home situation
be assessed because infant abuse and neglect are common in homes where there is
drug/alcohol abuse.
Incorrect: While this may be important information to know, it does not address the infant or its
care.
Incorrect: Assessing whether or not the mother has money enough to afford treatment for
her addiction is not as important as the infant's safety.
Incorrect: Drug withdrawal is not measured in degree of severity. The baby is withdrawing, and
that is all that is important.
The mother's ability to provide a safe environment
The extent of addiction of the mother
The mother's ability to obtain treatment
The severity of the infant' s withdrawal
57. A woman in active labor is admitted to the labor and delivery unit, accompanied by her
partner. As labor progresses, the nurse notes he is not interacting with the woman and sits in
the corner, looking out the window. How may the nurse understand the man's actions?
Incorrect: Other factors such as culture, personality, and language should be considered before
assessing the inability to cope due to overwhelming concern for the woman. At this point
there are no data to indicate overwhelming concern.
Correct: These factors must first be considered along with ability to speak the language.
Keeping in mind that there are individual and cultural differences in expressing
concern will enable the nurse to make unbiased assessments.
Incorrect: Embarrassment may be a reason for the man's actions, but is not the first
consideration. It is important to first consider that there individual and cultural differences in
expressing concern. This will enable the nurse to make unbiased assessments.
Incorrect: If a man's religious beliefs prohibited him from viewing a birth, he is not likely to be
in the room during the active phase of labor.
He is likely to be very concerned about the woman's health to the point that his ability to cope
with the situation is compromised.
His actions reflect personality or cultural differences, which do not necessarily indicate a lack of
concern.
Due to his embarrassment and discomfort regarding the woman's expressions of pain, he
withdraws from the situation.
His religious beliefs regarding participation in the birth experience affect his interactivity and
communication in this situation.
58. A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH).
The physician orders magnesium sulfate. Which nursing intervention is important when
administering this drug?
Correct: Because hypertension is a sign of PIH, the client's BP must be monitored. The
client's respiratory rate should be monitored because one sign of magnesium sulfate
toxicity is a respiratory rate under 12/min.
Incorrect: Assessing blood glucose levels does not pertain to PIH but to gestational diabetes.
Incorrect: A side effect of magnesium sulfate is a decrease in blood pressure, which might cause
orthostatic hypotension; however, the client with severe PIH will be on strict bed rest and not
allowed to walk.
Incorrect: Magnesium sulfate may be used for preterm labor to slow contractions, but this does
not pertain to PIH.
Assess blood pressure and respiratory rate every fifteen minutes.
Monitor blood glucose levels every eight hours.
Evaluate for orthostatic hypotension when getting the client up to walk.
Observe for premature labor every shift.
59. A 27-week gestation infant is taken to a newborn intensive care unit 150 miles away.
Initially, which emotion should the nurse expect the mother to display after the transfer?
Incorrect: Usually denial is seen when the mother fails to recognize the severity of the situation.
Denial would probably have occurred before the transfer, when the mother first learned about the
baby's critical status.
Incorrect: The mother may display frustration but it is aimed at not being able to follow the baby
to the intensive care unit, and lack of knowledge about the child's condition.
Correct: The mother feels a great deal of guilt for not having a perfect baby and perhaps
for causing the baby pain and discomfort. The mother may also feel that she could have
done something to prevent the early delivery. This is the primary emotion to expect.
Incorrect: Anger is not usually seen initially. It occurs later in the grieving
process. Denial
Frustration
Guilt
Anger
60. A 38 week gestation newborn weighs 4020 grams, is sluggish, and has limp muscle tone.
The baby experienced a broken clavicle during delivery. Based on this information, which can
the nurse conclude about the baby?
Incorrect: Normally infants who are withdrawing from drugs are hyperactive and jittery, not
lethargic and limp.
Correct: These symptoms indicate a large-for-gestational-age (LGA) infant. LGA infants
typically have diabetic mothers and have respiratory problems and difficulty with
stabilization of blood sugar.
Incorrect: The baby's signs and symptoms are reflective of large-for-gestational age, not a heart
defect.
Incorrect: Respiratory depression may cause the infant to be limp, but this does not account for
the baby's elevated weight.
Neonatal abstinence symptoms
Large for gestational age
Congenital cardiac defect
Respiratory depression
61. Which assessment finding suggests thrombophlebitis in a postpartum
client? Incorrect: These signs and symptoms are indications of pulmonary
embolism.
Incorrect: These are signs and symptoms of a pulmonary embolism. Pulmonary emboli may
occur as a result of clot formation in the calf.
Correct: These signs and symptoms are common for clients with thrombophlebitis.
Thrombophlebitis occurs because of changes in the blood volume and coagulation factors that
result after delivery. Although eliciting a Homan's sign could dislodge a thrombus, it is
considered a positive sign.
Incorrect: These signs and symptoms do not relate to thrombophlebitis.
Dyspnea, tachypnea, and apprehension
Chills, hypotension, and abdominal tenderness
Positive Homan's sign, calf warmth, and pain
Dizziness, loss of consciousness, and chest pain
62. A client comes to the clinic to confirm that she is pregnant. Her last menstrual period
was January 31st. According to Naegele's rule, when should the client expect to deliver?
Incorrect: Seven days have not been added.
Incorrect: Only two months have been subtracted.
Correct: When using Nagele's rule to estimate delivery dates, the nurse takes the client's
last menstrual period (LMP), adds 7days, and then subtracts 3 months. Adding 7 days to
the LMP of January 31st makes it February 7th. Subtracting 3 months then makes the due
date November 7th.Incorrect: Seven days have been subtracted instead of added to the
LMP.
November 31
December 7
November 7
December 24
63. Which procedure should be avoided for the client known to have a placenta previa?
Incorrect: Non-stress tests are necessary to monitor the well-being of the fetus. Non-stress tests
are usually performed if the client returns home after a bleeding episode.
Incorrect: Performing a catheterization has nothing to do with placenta previa.
Correct: In placenta previa, the placenta covers all or part of the cervical opening.
Therefore, vaginal exams are contraindicated because of risk of bleeding or infection.
Hemorrhage is the main complication of placenta previa.
Incorrect: Abdominal ultrasounds are non-invasive and are commonly performed upon
admission to
the hospital to locate the position of the placenta.
A non-stress test
A urinary catheterization
A sterile vaginal exam
An abdominal ultrasound
64. A woman in the first trimester comes to the clinic with vaginal bleeding. The physician
determines that the fetus has died and that the placenta, fetus, and tissues still remain in the
uterus. How should the findings be documented?
Incorrect: A complete abortion occurs when all products of conception are expelled.
Incorrect: Stillborn is a lay term that means the baby has died. This does not address the products
of conception such as the placenta or tissues.
Correct: Prolonged retention of the products of conception (placenta/tissues) after the fetus
has died is known as a missed abortion. Infection and coagulation defects are common
complications.
Incorrect: An incomplete abortion occurs when some, but not all, of the products of conception
have been expelled.
Complete abortion
Stillborn abortion
Missed abortion
Incomplete abortion
65. A woman in the transition stage of labor is using paced breathing to relieve pain. She
complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition
is indicated by these signs and symptoms?
Incorrect: Anoxia/hypoxia results in restlessness, nasal flaring, and cyanosis of the lips and
nailbeds. The signs and symptoms listed in the question are not related to anoxia.
Correct: These signs and symptoms are a result of hyperventilation. The nurse should have
the client breathe slower and into a paper bag to counteract the signs and symptoms.
Incorrect: Anxiety usually causes rapid heart rate and muscle tenseness, not the symptoms listed
in the question.
Incorrect: While hypertension often affects vision, it is not the reason for this cluster of
signs and symptoms.
Anoxia
Hyperventilation
Anxiety
Hypertension
66. Which data support a diagnosis of abruptio placenta in a pregnant woman?
Correct: These are classic signs of an abruptio placenta. Other signs and symptoms
include: dark, red vaginal bleeding, fetal distress, signs of hypovolemic shock.
Incorrect: These are signs of placenta previa, not abruptio placenta.
Incorrect: These have nothing to do with abruptio placenta.
Incorrect: Bright red blood loss is a sign of placenta previa. Hypertension may occur in abruptio
placenta, however.
Uterine rigidity and abdominal pain
Painless bleeding with soft abdomen
Premature rupture of membranes and uterine contractions
Bright red blood loss and elevated blood pressure
67. A women in her first trimester contracts rubella. How is the fetus likely to be
affected? Incorrect: Rubella is usually associated with hearing, vision and cardiac defects.
Correct: The rubella virus usually causes mild illness in the mother, but has devastating
effects on the fetus, including cataracts, heart defects (patent ductus arteriosus and
pulmonary stenosis are the most common), deafness, mental and motor retardation, growth
retardation and clotting disorders.
Incorrect: Spinal cord defects are a result of the inability of the vertebrae to fuse—it is a
congenital problem and not related to rubella.
Incorrect: Polydactyly, the presence of extra digits (fingers or toes), and club feet are not usually
seen in fetuses with rubella.
Reproductive and urinary defects
Heart defects and cataracts
Spinal cord and skeletal defects
Polydactyly and club feet
68. An hour after delivery, a 4000 gram infant exhibits pallor, jitteriness, a blood sugar level
of 40 gm/dL, irritability and periodic apnea. Which maternal condition could be the cause of
the newborn's symptoms?
Incorrect: Jitteriness and irritability may indicate a drug withdrawal problem, but the large birth
weight and the low glucose levels indicate an infant of a diabetic mother.
Incorrect: Jitteriness, irritability, and pallor are classic signs of hypoglycemia in the infant with
a history of gestational diabetes. Infants born to mothers with pregnancy induced hypertension
may be small for gestational age due to uteroplacental insufficiency.
Incorrect: TORCH infections do affect the baby, but the symptoms described do not indicate a
TORCH infection.
Correct: These signs and symptoms are classic of an infant of a diabetic mother.
Drug addiction
Pregnancy-induced hypertension
TORCH infection
Gestational diabetes
69. A client delivered vaginally six hours ago. Which assessment finding can be interpreted
as normal?
Correct: A slight elevation in temperature during the first 24 hours post-delivery may be a
result of dehydration. Temperature elevations after 24 hours are considered abnormal.
Incorrect: A reading of 140/90 may indicate hypertension, which is a serious complication.
Incorrect: A respiratory rate of 10 is not normal and could be a result of medications/narcotics
given during labor.
Incorrect: After delivery, the pulse rate is usually slightly lower than normal (usually 60-70
bpm) because of the fluid shifts and diuresis.
Temperature 100.0 degrees
F Blood pressure 140/90
Respirations 10
Pulse 90
70. A new mother receives instructions about care of her newborn son's circumcision.
Which statement made by the mother indicates that further teaching is needed?
Incorrect: The doctor should be notified if there is prolonged, excessive bleeding or signs of
infection.
Correct: This statement indicates that the client does not understand about the care of the
circumcision. The yellowish mucous is normal and is from accumulated yellow serum. It
helps in normal healing and should not be washed away.
Incorrect: Vaseline gauze or betadine ointment should be applied with each diaper change to
prevent the penis from sticking to the diaper.
Incorrect: Sponge baths should be given to circumcised babies for the first 7 to 10 days. If a
plastibell is used, tub baths may be given when the bell falls off (usually 7 –10 days).
"I will call the doctor if my baby's penis starts to bleed."
"I should wash off any yellowish mucous on my baby's penis."
"I will put vaseline on his penis every time I change his
diaper." "I should give my baby a sponge bath for the first
week."
71. A 17-year-old client delivered her first baby 8 hours ago. Which of the following is
an indication that appropriate bonding is occurring? The client:
Correct: Making eye contact is a sign of positive attachment. Other signs include: speaking
or singing to the infant, talking about the physical characteristics of the baby, (big feet,
little nose etc.), calling the baby by name, stroking or massaging the baby to quiet it.
Incorrect: Asking why the baby cries is not a sign of attachment and it may be a sign of rejection
or neglect.
Incorrect: This may indicate the lack of caretaker responsibility. Participation in infant care
increases bonding.
Incorrect: Asking if the baby is cute is not an indication that an attachment is occurring. The
nurse's response must be carefully thought out to avoid blocking expressions of concern by the
client.
makes eye contact with the baby.
wonders why the baby cries so much.
asks the nurse to help change the baby' s
diaper. asks the nurse if the baby is cute.
72. A new mother is crying in her room. She tells the nurse that her new baby boy has
enlarged breasts and she thinks that there is something wrong. How should the nurse respond?
Incorrect: This statement would increase the client's worry and anxiety by confirming her fears
that something is wrong. The baby's symptom is completely normal.
Correct: Enlarged breasts are common as a result of hormonal withdrawal. Breast
enlargement usually subsides within the first few weeks after delivery. This response
provides the mother with information, which should decrease her anxiety.
Incorrect: This may be an appropriate response, but should not be the nurse's first response
because it suggests the possibility that something is wrong with the baby. The baby's symptom is
completely normal.
Incorrect: This statement is an example of meaningless reassurance.
"You should ask your doctor about that."
"Enlarged breasts are common for both boys and girls. It will go
away." "Let me look at the baby for you."
"Everything is going to be just fine. Your baby is healthy."
73. During the active phase of labor, the membranes rupture and the nurse notes green
amniotic fluid. Which nursing action should be initiated immediately?
Incorrect: Green amniotic fluid is an indication of meconium staining, which may indicate fetal
distress. The physician should be notified but not before assessing the status of the fetus.
Incorrect: This is a comfort measure. It can wait until after the nurse assesses for fetal distress.
Incorrect: Testing the fluid usually differentiates amniotic fluid from urine.
Correct: Any time the membranes rupture, the nurse should immediately assess fetal
heart rate, especially when the fluid is meconium stained, as this may indicate fetal
distress.
Call the physician.
Replace the soiled underpad.
Test the fluid with pH (Nitrazine)
paper. Assess fetal heart rate.
74. At 28 weeks gestation, a woman enters the hospital in preterm labor and receives
atocolytic medication to stop labor. Which assessment findings should be reported
immediately to the physician?
Incorrect: Fetal heart rate of 160 is considered normal. Incorrect: These represent Braxton Hick
contractions, not true labor. Contractions should be monitored closely for intensity, frequency
and duration. Incorrect: The vital signs are within normal limits.
Correct: Ferning is an indication of amniotic fluid, which indicates that the membranes are
ruptured. This should be reported immediately because delivery may be imminent. With
ruptured membranes, the client should be monitored for infection.
Fetal heart rate averaging 160 beats/min
Irregular contractions every 15-20 minutes that last 30 seconds before stopping
Maternal temperature 98.8 degrees F, pulse 84, respiratory rate 22, BP 130/70
Ferning pattern of vaginal discharge under a microscope
75. A labor and delivery nurse suspects that a client is in the transition stage of labor.
Which information supports this conclusion? The client is:
Incorrect: These are typical signs of the latent or early phase of labor.
Correct: These are typical signs of the transition phase of labor. In addition to irritability
and the inability to focus, the client may exhibit anger, loss of control, anxiety, mood
swings, rectal pressure, and increasing amounts of pain.
Incorrect: These occur in the second stage of labor, just prior to birth. Incorrect: These are signs
that the client is in the latent or early phase of labor.
walking around the unit and talking with her
partner. irritable and needs frequent repetition of
directions. expelling feces and the fetal head is
crowning. reading a magazine and talking on the
phone.
ATI. CHILD CARE 2.0
1 The parents of a 5-month-old infant state that their infant seems to eat very little. Most of the
food comes out of the infant's mouth and onto his clothes. Which of the following
explanations should the nurse give to the parents?
Trying to introduce food after the intake of a bottle formula is usually not recommended because
the infant is satiated and has no inclination to try something new. Solid foods should be offered
at 4 to 6 months. The gastrointestinal tract has matured enough to handle more nutrients and is
less sensitive to potentially allergenic foods. This deprives the infant of the pleasure of learning
new tastes and developing a discriminating palate. It may cause problems with poor chewing
because of lack of experience. Due to the extrusion (protrusion) reflex, the infant’s tongue
pushes the food out of the mouth. It is most helpful to suggest using a long-handled spoon and
placing the food in the back of the infant's mouth to avoid the reflex.
"Give the baby a bottle of formula before solid food to assure adequate caloric intake."
"Stop the solid foods and try again when the baby is 12 months old."
"Put the cereal in a bottle and feed the baby through a nipple with a large hole."
"Place the food in the back of the baby's mouth using a long-handled spoon."
2 A nurse smells an odor identified as marijuana coming from a room. Which of the
following client findings would confirm inhalation of the substance?
All are findings of a client who has smoked/inhaled cannabis/marijuana. These clients are
typically euphoric or somewhat mildly intoxicated. They have poor coordination with bloodshot
(red) eyes and may laugh inappropriately. These findings are more commonly due to of the
effects of depressants. These findings are more commonly due to the effects of opiates. These
findings are more commonly due to the effects of cocaine.
Poor coordination, red eyes, and euphoria
Slurred speech, confusion, and combativeness
Loss of consciousness, respiratory depression, and coma
Hypertension, tachycardia, and hyperflexia
3 A nurse is checking children at an orthopedic outpatient setting. Which of the following
should the nurse expect to see as manifestations of scoliosis?
Lumbar curvature is a manifestation of lordosis. These are manifestations of scoliosis. Often
parents observe that a child's skirt doesn't hang straight or the pant legs are uneven. Tenderness is
a general symptom that may indicate something is wrong in an underlying organ. A nurse could
not see changes such as swelling of the spine. These symptoms could be associated with other
orthopedic problems but are not characteristic of scoliosis.
Pain and an exaggerated lumbar curvature
Uneven shoulder heights and poorly fitting slacks
Tenderness and swelling of the spine
Limited range of motion of the back and a limp
4 A nurse is providing client/patient education to the mother of an 8-year-old child diagnosed
with B-hemolytic streptococci infection (strep throat). The nurse emphasizes the importance
of promptly starting and completing the entire course of antibiotics. The mother asks why this
is important. The nurse states that the antibiotic will
Pain may interfere with oral intake, but this is not the priority concern with prompt diagnosis and
care of strep throat. Cool fluids or ice chips may be comforting. Relief to the neck may be
provided by the application of cold or warm compresses to the area. Warm saline gargles may
also relieve throat discomfort. Sinusitis and abscess formation on the pharyngeal and peri
tonsillar areas are complications that can develop with a strep throat infection, but these
complications are not of the greatest concern with this infection. Anterior cervical
lymphadenopathy is a symptom of a streptococcal infection resulting in pharyngitis and tender
lymph nodes. This usually subsides in 3 to 5 days if uncomplicated. Antibiotics should be
initiated as soon as possible and taken as prescribed to quickly and completely eliminate the
streptococcal organism, which can lead to acute rheumatic fever, glomerulonephritis, and acute
renal failure.
alleviate painful swallowing to avoid complications of dehydration and malnutrition.
prevent sinusitis or abscess formation on the pharyngeal or peri tonsillar areas.
reduce the risk of anterior cervical lymphadenopathy.
eliminate organisms that might initiate acute renal failure or rheumatic fever.
5 A nurse is reinforcing teaching about accidental poisoning to a parent during a routine
well- child visit. The nurse asks the parent, "What would be your first response if your child
accidentally took an overdose of acetaminophen (Tylenol)?" Which of the following
statements by the parent would indicate a correct understanding?
Syrup of ipecac is no longer recommended as a routine home treatment of poisoning. Giving
syrup of ipecac might possibly be appropriate, but certain substances that are corrosive would
make using this measure contraindicated because it would increase the damage to the mucosa
lining. Placing the child into a side-lying position is an appropriate measure to prevent aspiration.
Calling the Poison Control Center is the best initial response to an accidental poisoning because
each case needs to be dealt with by getting prompt medical attention to initiate the appropriate
emergency treatment actions. Giving the child one sip of water, not a full glass, is appropriate to
dilute the ingested poison. However, this is not the first action that should be taken.
"I will give my child a dose of ipecac."
"I will place my child on her back."
"I will call the Poison Control Center."
"I will get my child to drink a full glass of water."
6 A nurse is caring for a 23-month-old child with iron-deficiency anemia. The parents indicate
they have been taught about the diagnosis, but are concerned that they are not doing all that they
need to do. Which of the following should the nurse include when reinforcing teaching?
Cow's milk contains substances that bind with iron and interfere with its absorption. Iron should
not be given with milk or milk products. There are no food limitations or suggestions when
children are taking oral iron preparations. Foods with vitamin C, such as citrus fruits, enhance
the absorption of iron. Oral iron supplements do not cause GI bleeding or ulcers. Liquid iron may
stain the teeth, so the nurse should instruct the parents to give it through a straw placed in the
back of the child's mouth to avoid staining the teeth.
Give the oral iron supplementation with a glass of cow's milk to prevent stomach problems.
Provide diet instructions including limiting citrus fruits in favor of more vegetables.
Provide information about complications of iron including gastrointestinal bleeding and ulcers.
Give liquid iron through a straw placed in the back of the mouth.
7 A nurse is reviewing discharge teaching with the parents of a child who has pediculosis.
Which of the following should the nurse include in the teaching?
Children should not share combs, hair ornaments, hats, caps, scarves, coats, and other items used
on or near the hair. Pets are not carriers of lice. Clothes should be dried in a hot dryer for at least
20 min to kill the lice. Lice need a blood source to survive. Placing the nonwashable items in a
sealed plastic bag for 14 days will kill the lice.
"Children can share scarves and coats, but not hats or combs."
"Household pets can carry and transmit lice to people."
"After washing clothing, hang clothes outside to
dry." "Seal nonwashable items in plastic bags for 14
days."
8 A nurse is caring for a toddler who is in an oxygen tent. Which of the following
actions should the nurse take in order to promote comfort while maintaining the child's
safety?
Not all toys are safe to put inside an oxygen tent. Vinyl or plastic toys that do not absorb
moisture are suitable to put inside the tent. Stuffed animals absorb moisture and are difficult to
dry. High levels of oxygen are a source of sparks, so mechanical or electrical toys are a potential
fire hazard. The moisture inside an oxygen tent will make the child cold and the child’s clothes
moist. Therefore, the nurse should try to keep the child warm and dry by changing bedding and
clothes, which will enhance the child's comfort without compromising safety. Oxygen is heavier
than air; therefore, oxygen loss will be greater at the bottom of the tent. The tent should be
tucked snugly without open edges to prevent oxygen loss. Some tents are opened at the top.
Oxygen is a heavy gas and most of it will stay at the bottom of the tent. This measure does not
promote the child's comfort while in the oxygen tent.
Give the child a stuffed animal and car with rubber wheels to play with.
Change the bedding and the child's clothing frequently or as often as needed.
Tuck the bottom of the tent under the mattress on three sides, leaving one side open so the child
can look out.
Cover the opening on the roof of the tent with a blanket to prevent the child from becoming
chilled.
9 A nurse is reinforcing teaching with the parent of a child with a urinary tract infection.
Which of the following statements made by the parent indicates understanding of how to
prevent future infections?
Children should be encouraged to void frequently, especially before long trips or other
circumstances in which toilet facilities may not be available for an extended period of time.
Urine that is held can harbor bacteria that can result in a urinary tract infection. Cotton
underwear allows for more air flow to the perineal area and reduces the risk of urinary tract
infections. Wiping from back to front increases the risk of feces entering the urethra and causing
a urinary tract infection. Bubble baths and perfumed perineal products can irritate the urethra and
lead to a urinary tract infection. These should be avoided, especially for girls.
"I will bring my child to the bathroom before we leave for extended trips."
"I need to switch my child from cotton underwear to nylon underwear."
"I should teach my child to wipe from back to front after urinating."
"I will have my child soak in a bubble bath once or twice a week."
10 A nurse is reviewing discharge instructions with the parent of an infant who has
acute laryngotracheobronchitis (croup). Which of the following statements made by the
parent indicates a need for further teaching?
This is a correct intervention. Corticosteroids have an anti-inflammatory effect that decreases
subglottic edema. This will make breathing easier. This is a correct intervention. Clearing the
nasal passages decreases the amount of secretions in the upper and lower airways. Dry air will
exacerbate the child's croup. Cool temperature therapies are advocated for this condition. Cool
mist constricts edematous blood vessels. A cool air vaporizer can be used at home to maintain
high humidity and provide relief. Warm mist from warm running water such as a hot shower in a
closed bathroom may be beneficial. It is essential that children with laryngotracheobronchitis
(croup) be allowed and encouraged to drink any fluids they like to increase fluid intake.
"I will give my child the corticosteroids prescribed by the doctor."
"I will clear the child's nasal passages with a bulb syringe to aid in breathing."
"I will place a dehumidifier in my child's room."
"I will encourage my child to take plenty of fluids over the next several days."
11 A 15-year-old client visits the clinic to get medical clearance to play a sport. The nurse
reviews measures to prevent athlete's foot with the client. Which of the following statements by
the client indicates that the instructions were understood?
Many people believe tinea pedis is transmitted via showering in the same location as someone
who is infected. However, transmission of tinea pedis to other individuals is rare. Ointments
have not proven to be successful in treating tinea pedis. Application of antifungal powder
containing tolnaftate or tolnaftate liquid is a treatment measure. Medication is not usually
recommended as a preventative measure. The client should avoid heat and perspiration by
wearing light socks.
Wearing well-ventilated shoes and clean, lightweight socks is encouraged in order to prevent
heat and perspiration conditions. Occlusive shoes should be avoided.
"I will avoid showering at the gym."
"I can apply an antifungal cream
daily." "I should wear dark-colored
socks."
"I should wear well-ventilated shoes."
12 A nurse is collecting data on a 3-year-old child with eczema in an outpatient center. The
parent asks whether any changes can be made at home to prevent the recurrence of eczema.
Which of the following is an appropriate response by the nurse?
Clients with eczema should avoid any material that produces heat, as this can cause perspiration
and itching. Bubble baths and harsh soaps cause drying of the skin and can further irritate the
eczema. A room humidifier or vaporizer may be helpful for keeping moisture in the air and
keeping the skin from drying. Woolen clothing or blankets cause itching and should not be used.
"Cover the crib mattress with a plastic cover."
"Give the child a bubble bath for 20 min each
day." "Place a humidifier in the child's room."
"Dress the child in warm wool clothing in cold weather."
13 A nurse is caring for a 7-year-old child who is admitted with an asthma exacerbation.
This is the third admission since diagnosis 6 months ago. Which of the following topics
should be reinforced with the parents and child in order to prevent future readmissions?
Monitoring the child's oxygen saturation and respiratory rate provides information about how
well the child is oxygenating, but does not prevent future attacks. Allergen control is aimed at
the prevention of exposure to airborne allergens and irritants that can trigger an asthma attack.
Preventing exposure to allergens does reduce the risk for future attacks. Peak flow readings
allow parents to make educated decisions regarding asthma management. However, these
measurements will not prevent future asthma attacks or hospitalization. Upright positioning is
important to help with lung expansion during an asthma attack, but it is not a preventative
measure.
Monitoring oxygen saturation and respiratory rate daily
Identification and avoidance of factors that trigger symptoms
Monitoring peak flow measurements regularly
Positioning the client upright in a position of comfort
14 Which of the following physical manifestations of a client with anorexia nervosa best
indicates compliance with the treatment plan of care?
Effectiveness of nursing interventions includes weight gain or no further weight loss. Measuring
weight is routinely completed to determine the effectiveness of the plan of care. This is the best
indicator of compliance with the treatment plan. Return of soft bowel movements indicates that
the client is not using laxatives or enemas to speed up the intestinal passage of food. This is a
good indication but is not the best indicator of compliance. This is a good indication of weight
gain and normalizing of body function, but it is not the best indication of treatment plan success.
Improvement of the oral mucosa indicates that nutritional deficiencies are improving. This is a
positive sign, but not the best indicator of compliance with the treatment plan of care.
A weekly weight gain of 1 kg (2.2
lb) Daily bowel movements that are
soft Return of regular menstrual
periods Improvement of the oral
mucosa
15 An assistive personnel (AP) is caring for a child diagnosed with leukemia and
undergoing chemotherapy. In which of the following clinical situations should a nurse
intervene?
Chemotherapy can damage gastrointestinal mucosal cells. Using a soft toothbrush will provide
mouth care and will be gentle on the mucous membranes in order to prevent ulceration. Hair loss
is a common side effect of chemotherapy. Children often feel better if their heads are covered so
no one can see that they have lost their hair. A soft cap is most comfortable and won't increase
perspiration or cause itching as do other materials. Chemotherapy will put children at risk for
infection secondary to immunosuppression, so all visitors with infections are restricted. The
rectal area is prone to ulceration from various drugs, feces, and urine. Urine and feces must be
removed immediately and the perianal area washed. Using rectal temperatures is avoided to
prevent trauma.
The AP offers a soft toothbrush for oral care.
The AP applies a soft cotton cap to the child's head.
The AP maintains a restriction of all visitors and health personnel with infections.
The AP prepares to take a rectal temperature.
???16 A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old
infant. Which of the following is the preferred injection site? (PICTURE HERE)
The vastus lateralis is the preferred site for IM injections in infants. The deltoid muscle is not the
preferred site for IM injections in infants. It is recommended that the ventrogluteal site not be
used until infants begin walking.
17 A nurse is reinforcing teaching with the parent of an infant who has club feet with
bilateral casts. Which of the following statements should be included in the teaching?
If a cast is too tight, circulation will be impaired and the toes will swell. Serial manipulation and
casting allows for the gradual stretching of skin and accommodates the rapid growth in early
infancy, and is performed every week for 8 to 12 weeks. If normal alignment is not achieved by
3 months, surgical intervention is indicated and will take place at about 6 to 12months of age. It
can take 24 to 48 hr for the cast to dry completely. A regular fan or cool-air hair dryer to
circulate air may facilitate drying when humidity is high. Heated fans and dryers should not be
used because they can cause the cast to dry on the outside but remain wet on the inside. They
may also cause burns from the conduction of heat from the cast to the underlying tissue. Pain is
not a problem associated with casting for club feet.
"Check the toes for any swelling or discoloration."
"Monthly recasting should be scheduled with the orthopedist."
"Use a heated fan or dryer to facilitate the drying of the cast."
"Give the baby Tylenol every 4 hr to help with pain."
18 A nurse is caring for a child with measles. Which of the following actions is
appropriate supportive care?
Photophobia accompanies rubeola; therefore, diversional activities with bright lights are
contraindicated. Dimming the room lights is soothing for the child. Isolation should be until day
5of the rash. The period of communicability is from 4 days before the appearance of the rash
until5 days following the appearance of the rash. An elevated temperature is common.
Overheating, which increases itching, should be avoided. The child should wear lightweight,
loose, and nonirritating clothing, and keep out of the sun. Antipyretics should also be
administered. Vitamin A supplementation reduces the morbidity and mortality in children
with the measles. Children with measles should be given vitamin A supplements. Nurses need
to instruct parents on safe storage and administration of vitamin A to prevent excessive
administration and possible toxicity.
Provide diversional activities such as video games.
Maintain isolation for 48 hr after the rash resolves.
Keep the child warm with adequate undergarments and
bedding. Administer vitamin A supplements as prescribed.
19 A nurse is caring for a 14-year-old client diagnosed with diabetes mellitus. The nurse is
discussing the ongoing monitoring needed with this diagnosis. Which of the following should
be included in the discussion?
When children are ill their fluid intake should be monitored. They often drink less, leading to
dehydration. When children are hyperglycemic, dehydration from illness leads to increased
hyperglycemia and requires extra fluid intake. Exercise results in increased movement of glucose
into the cells and decreased blood glucose levels. The client should have a snack, not additional
insulin. There is poor correlation between glycosuria and blood glucose. Blood glucose
monitoring is much more accurate than urine glucose monitoring. Children with diabetes should
increase the amount of whole grains, fruits, and vegetables, which contain complex
carbohydrates, in their diets. Concentrated sweets are avoided to prevent hyperglycemia.
The illness requires careful attention to fluid balance since hyperglycemia contributes to
dehydration.
Exercise requires additional insulin since glucose will be released from the cells during activity.
Urine glucose must be monitored because there is a correlation between simultaneous glycosuria
and blood glucose concentrations.
The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose.
20 A nurse is reinforcing teaching with the parent of a 4-year-old child with influenza. Which
of the following should the nurse include in the teaching?
Influenza is spread by direct contact. This means it can be spread from one person to another or
by touching an object that has been contaminated by nasopharyngeal secretions. The most
infectious period for influenza is 24 hr before and after the onset of symptoms. There is a
possible link between aspirin and Reye syndrome, so children with influenza or other viral
illnesses should not be given aspirin. Most cases of Reye syndrome follow a common viral
illness such as chickenpox or influenza. The immunization vaccine can be given at the same
time as other vaccines, but must be given in a separate syringe and at a different injection site.
Influenza is transmitted by airborne means, so handwashing will not prevent transmission.
Children are not infectious after 12 hr from the onset of influenza symptoms.
Aspirin should not be given to children with influenza for relief of discomfort.
The influenza vaccine may not be given at the same time as other immunizations.
21 A nurse is discussing nutrition with an adolescent who is pregnant. The adolescent's parent
is in the room. Which of the following statements made by the parent indicates a need for
further dietary instruction?
This statement needs clarification. Snacks containing sugar are often eaten by the adolescent who
is pregnant, but are not a good source of calories for energy and nutrition for the developing
fetus. Whether pregnant or not, an adolescent's nutritional needs include an increase in calcium,
protein, and iron. Nutritious between-meal snacks are a good source of energy. Complex
carbohydrates of wheat and whole grains and fruits are appropriate snacks. This is a good
suggestion because the adolescent does need additional calories in the second and third trimester.
"I told my daughter that any calories ingested are a source of energy and nutrition."
"I try to provide foods with an increased amount of calcium, protein, and iron."
"I encourage between-meal snacks that are complex carbohydrates and fruits."
"I have planned meals and snacks for additional calories in the second and third trimester."
22 A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a
scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan
of the abdomen and tells the nurse the pain just stopped. Which of the following should the
nurse do first?
Even though continued pain assessment is important, this is not the first priority with the sudden
relief of pain. The child's vital signs will need to be taken before surgery, but this is not the
priority at this time. The sudden cessation of pain in a child with appendicitis should cause the
nurse to suspect a ruptured appendix. The primary care provider should be notified immediately
since the client is at increased risk for developing peritonitis, which can cause death if
appropriate interventions are not immediately taken. The nurse would assess bowel sounds as
the child is prepared for surgery, but this is not the priority at this time.
Continue with the pain assessment.
Take the child's vital signs.
Notify the primary care provider.
Auscultate the child's bowel sounds.
23 A nurse is monitoring a 9-year-old child on the first postoperative day following
abdominal surgery. The nurse notes the child grimacing and guarding her abdomen. Which of
the following pain assessment tools should the nurse use based on its acceptance by children?
The poker chip scale is used by children, but is not rated as the most preferred by that age group.
The FACES pain rating scale is the best choice for a 9-year-old child because it includes visual
face, numerical correspondence, and text stating feelings. This is the most preferred scale for
children. The visual analog scale allows a child to mark a line stating the length of pain;
however, this scale is difficult to determine and clarification is needed. The numerical 1 to 10
rating scale is used for adults. It has too many options and often requires clarification when used
with children.
Poker chip tool
FACES rating
scale Visual analog
scale
Numerical 1 to 10 rating scale
24 A nurse is reinforcing teaching to a group of parents about preventing accidental poisoning
in preschoolers. Which of the following should the nurse include?
This does not prevent accidental poisoning. Parents should caution against eating inedible items
such as houseplants. Never remove labels from containers of toxic substances. Store toxic agents
in a locked cabinet. All potentially toxic agents should be placed out of reaching a locked
cabinet. Toddlers may be able to climb onto the sink and get into the cabinet.
Have syrup of ipecac available in the home.
Explain to preschool children that plants can be eaten only after they are cooked.
Keep labels on containers of toxic substances and never remove them.
Place medications in a cabinet above the sink.
25 A nurse is caring for a 4-month-old infant with thrush (candidiasis) who is breastfed.
Which of the following is an appropriate nursing action?
To prevent relapse, therapy with nystatin should be continued for at least 2 days after the
lesions disappear. No change in feeding is needed as part of the care for a client with thrush. No
change in feeding is needed as part of the care for a client with thrush. Sucking may be painful,
but changing to a formula or another method of feeding will not alleviate the discomfort. Oral
candidiasis cannot be removed with a tongue blade and attempting to do so will cause bleeding
and discomfort for the infant.
Administer the prescribed nystatin (Mycostatin) for 2 to 3 days after the lesions disappear.
Place the infant on a soy-based formula to supplement breastfeeding until thrush is resolved.
Discontinue breastfeeding and resume 48 hr after the last lesion disappears.
Scrape off the white patches of thrush from the oral mucous membrane with a tongue depressor.
26 A nurse is caring for an adolescent with inadequate weight gain. Which of the following
nutritional considerations is important to reinforce when talking with the client about appropriate
nutrition?
Generally, adolescents obtain or exceed the recommended carbohydrate consumption. Limiting
fat consumption is important to overall health. Adolescence is a time of accelerated physical
growth, which can include doubling the adolescent requirements of calcium, iron, zinc, and
protein. Maximum bone mass is acquired during adolescence making calcium intake during
these years essential. Just increasing calories will not ensure adequate consumption of the
necessary vitamins and minerals necessary to assure good health.
Identify food preferences high in complex carbohydrates.
Identify food preferences high in saturated and unsaturated fats.
Identify food preferences high in calcium and protein.
Identify food preferences high in calories.
27 A primary care provider prescribes amoxicillin suspension to a child with otitis media
who weighs 22 lb. The prescription reads: 30 mg/kg/day in divided doses every 8 hr. The
pharmacy carries the medication as 200 mg/5 mL. How may mL should the nurse give in one
dose?
Answer in mL.
mL First, convert the client's weight to kg: 2.2 lb = 1 kg, so 22 lb = 10
kg. 24 hr/day = 3 doses/day
8 hr/dose
30 mg/kg/day = 10 mg/kg/dose
3 doses
10 mg x 10 kg = 100 mg every 8 hr
The desired dose is 100 mg. The medication is available as 200 mg/5
mL. 100 mg/x mL = (½)5 mL
200 mg/5 mL
5 mL = 2.5
mL/dose  2
First, convert the client's weight to kg: 2.2 lb = 1 kg, so 22 lb = 10 kg.
24 hr/day = 3 doses/day
8 hr/dose 30 mg/kg/day = 10 mg/kg/dose3 doses
10 mg x 10 kg = 100 mg every 8 hr
The desired dose is 100 mg. The medication is available as 200 mg/5
mL. 100 mg/x mL = (½)5 mL200 mg/5 mL
5 mL = 2.5 mL/dose 2
28 Which of the following approaches is the most accurate way to measure the heart rate of a
10month-old infant?
The apical heart rate is auscultated and is the most accurate measurement for an infant. The
radial pulse is not palpable in an infant. The ulnar vein is deep in the arm and is not palpable.
The brachial pulse is palpable in an infant. It provides a quick check of circulation status, but it is
not the most accurate approach.
Apical
Radial
Ulna
Brachial
29 A nurse is caring for a 4-year-old child diagnosed with leukemia who is
admitted with myelosuppression. Which of the following actions should the nurse
take?
High carbohydrates will not provide the proper nutrients for protection against infection. The
child needs a diet high in protein for defense against infection. Chemotherapy can cause injury to
mucous cells lining the rectal area, making this area prone to ulceration and tears. Rectal
temperatures should be avoided to prevent trauma to this fragile tissue. Lemon and glycerin
swabs are abrasive and can irritate tissue. A break in the skin is a potential source of infection.
Provide a diet high in carbohydrates.
Monitor rectal temperature every 4 hr.
Use lemon or glycerin swabs for oral care.
Inspect the skin daily for lesions.
30 The parents of a 4-year-old child state that they had an infant die 2 months ago during
childbirth. They are concerned about their 4-year-old child's response to the infant's death.
Which of the following statements by the parents indicates an expected response about death
from the 4- year-old child?
This expresses a more adult understanding of death. Preschoolers tend to think that the sibling is
still alive. This kind of question would be appropriate for a school-age child. These responses are
most characteristic of adolescents who have the most difficulty coping with death. Young
children often feel guilty and responsible for a sibling's death, or may view illness or injury as a
punishment for their thoughts about the sibling.
"Our child wants to go to the cemetery to be with his sister."
"Our child asks many questions about what happened to the baby's body."
"Our child is not sleeping, eating, or playing lately and we are worried."
"Our child blames himself for the baby's death because he said he didn't want a baby brother or
sister."
31 A nurse is preparing a room for the admission of a client with sickle cell anemia who is
in vasoocclusive crisis. Which type of equipment should the nurse place in the client's
room?
Wheelchairs are used to decrease energy expenditures; however, this is not the most important
equipment needed at this time. It would be nice to have these available in the room, but these are
not priority measures at this time. It would be nice to have these available in the room, but these
are not priority measures. Exchange transfusion is an important part of the treatment for vaso-
occlusive crisis. One of the main objectives when managing a sickle cell crisis is blood
replacement to treat anemia and hydration to reduce the viscosity of the sickled blood.
Wheelchair with adjustable leg rests
A radio and age-appropriate reading
materials Extra blankets and pillows
Blood transfusion equipment
32 An 8-year-old child is admitted to a pediatric unit with a fractured femur and is placed
in skeletaltraction. Which of the following nursing interventions is the most appropriate?
Weights should hang freely to promote the forward force of traction. High-fat meals are not
recommended. When a client is immobile, a high-fiber diet may be recommended to keep stools
soft and prevent complications. The pulses on the side that are in traction are compared to the
pulses on the contralateral side to assure that circulation in the affected side is not compromised.
Color of the skin and nailbeds can also be assessed to observe for any neurovascular changes.
The child's position should be changed at least every 2 hr to relieve frictional pressure on the bed
and minimize skin breakdown. Passive, active, or active-with resistance exercises of the
uninvolved extremities and joints should be performed to maintain strength and range of motion.
Dependent upon the type of traction, varying degrees of position changes can be made without
interfering with the traction.
Position the weights securely against the foot of the bed.
Provide small, frequent, high-fat meals to the child.
Compare pulses on affected site to contralateral side.
Provide diversional activities to minimize the child's movement.
33 A nurse on a pediatric unit is assigned to care for a child with Reye syndrome. Which of
the following is the most serious clinical manifestations for which the nurse should monitor?
Reye syndrome results in children secondary to a mitochondrial insult sustained following a viral
infection and the administration of aspirin. It is not associated with an anaphylactic reaction.
Cerebral edema with increased intracranial pressure presents the most significant threat to life.
Vital functions and neurologic status need to be monitored by the nurse. Secondary to related
liver dysfunction, coagulation impairment with prolonged bleeding time is a sign of Reye
syndrome. This complication is not the most serious clinical manifestation of Reye syndrome.
The possibility of hypovolemic shock is a constant threat in children with controlled fluid intake
and osmotic diuresis. Monitoring of intake and output is necessary for adjusting fluid volumes to
prevent dehydration.
Anaphylaxis
Cerebral edema
Impaired coagulation
Hypervolemia
34 A nurse is preparing to take a rectal temperature on a 7-month-old infant. Which of
the following should the nurse keep in mind when preparing to take the temperature?
A rectal thermometer should be well-lubricated prior to insertion, but the maximum depth of tip
insertion is 2.5 cm into the rectum, not inches. Rectal temperatures are approximately 1° Chigher
than an oral temperature. To convert from Fahrenheit to Celsius: (5/9)(x-32)=° C. For example, a
rectal temperature of 99.6° F is converted to Celsius by performing (5/9)(99.6-32)=(5/9)
(67.6)=338/9=37.5° C. Next, the oral temperature of 97.7° F is converted to Celsius by
performing (5/9)(97.7-32)=(5/9)(65.7)=328.5/9=36.5° C. The rectal temperature of 37.5° C is 1°
higher than the oral temperature of 36.5° C. Therefore, a rectal temperature of 99.6° F is
equivalent to an oral temperature of 97.7° F. Rectal temperatures are more accurate, but infants
should have their temperature taken by axillary or tympanic membrane because of the danger of
damaging rectal mucosa. Rectal temperatures should only be obtained on infants and children
when no other route can be used. Rectal thermometers should be left in place for 4min, but the
use of mercury thermometers is losing favor. Mercury thermometers should not be used because
if broken, inhaled vapors from the mercury can cause significant toxicity.
A well-lubricated thermometer tip should be inserted a maximum of 2.5 in into the rectum.
A rectal temperature of 99.6° F is equal to an oral temperature of 97.7° F.
Infants should have temperatures taken rectally for accuracy and thermoregulation.
Mercury thermometers are the thermometers of choice to obtain the rectal temperature, holding it
in place for 4 min.
35 A nurse is talking to the parents of a 3-year-old child about water safety precautions. Which
of the following statements made by the parents indicates a need for clarification?
Toddlers are curious and can fall headfirst and be trapped. Toddlers can drown in bathtubs while
being left unattended. Toddlers can drown in unusual places due to their curiousness and
fascination with water. All standing amounts of water should be drained. Teaching swimming
and water safety are beneficial, but insufficient for protection against drowning. When the child
is near the swimming pool, the parent needs to be supervising the toddler. Statistics show that
90% of all drownings occur in the swimming pool. Water is fascinating to children and
drowning can occur quickly.
"We keep the toilet seat down at all times."
"We don't answer the phone during bath
time." "We empty all buckets filled with
water."
"We have our child in swimming lessons."
36 A nurse is caring for a child with Wilms' tumor. The parents ask why the sign "Do not
palpate the abdomen" has to be placed on their child's bed. Which of the following is the correct
response by the nurse?
This is not the reason the abdomen should not be palpated. Wilms' tumor is characteristically
nontender. Palpation will not cause the tumor to grow. Tumors grow from multiplication of
cells, not manipulation of the mass. Palpation of the abdomen is avoided because manipulation
of the mass may cause cancer cells to spread to other sites. The tumor is on the kidney, not the
bladder. Palpation will not cause urinary leakage.
"Any manipulation of the abdomen can result in pain for your child."
"Palpation of the abdomen could cause the tumor to grow."
"Palpation of the abdomen could result in some of the tumor cells breaking loose,
causing it to spread."
"Any manipulation of the abdomen will put pressure on the bladder and cause urine to leak."
37 A nurse is caring for a child with muscular dystrophy. Which of the following priority
actions should the nurse include in the care of this child?
Maintaining function of muscles is the goal of treatment for muscular dystrophy. Stretching,
range-of-motion exercises, and strength and muscle training should be performed to help
maintain function. Children who remain active can delay the eventual confinement in wheelchair
for a great length of time. Duchenne muscular dystrophy occurs from mother-to-son
transmission of the defective gene. It is inherited from an X-linked trait. Therefore, genetic
counseling is an important aspect of supportive family care and it is recommended for the
parents, female siblings, maternal aunts, and their female offspring. This is not the priority
nursing action. Flu and pneumococcal vaccines are encouraged as well as the avoidance of
persons with respiratory infections because children with muscular dystrophy are at an increased
risk for respiratory infections. Incentive spirometer use and breathing exercises should be
performed daily to increase and maintain vital lung capacity.
Limit physical activity and plan frequent rest periods to avoid overexertion and exhaustion of
muscle groups.
Recommend genetic counseling for parents, male siblings, and paternal uncles and their male
offspring.
Advise against flu and pneumococcal vaccines due to a compromised respiratory system.
Have the child use an incentive spirometer and perform breathing exercises routinely.
38 A nurse is caring for a child with acute glomerulonephritis. The child has edema,
hypertension, and gross hematuria. Which of the following is the most appropriate
nursing intervention?
Children with glomerulonephritis require frequent monitoring of vital signs, but oxygen
saturation is not necessary. For children with hypertension and edema, moderate sodium and
fluid restrictions may be instituted. Foods high in potassium are restricted during oliguric
periods. Due to the edema present in the disease process, the child is weighed and fluid balances
monitored daily to check the fluid balance. This is not the first priority in the child's care. Most
children recover completely. However, health supervision following hospitalization should be
continued weekly and then monthly for evaluation and urinalysis.
Monitor the oxygen saturation every 4 hr.
Teach the parents dietary restrictions regarding
protein. Weigh the child daily and record intake and
output.
Counsel the parents about the need for follow-up.
39 A nurse is performing a routine physical examination on an adolescent client who asks, "Why
do I have to use a condom if my girlfriend is on the pill? I thought the pill was enough protection
against pregnancy." Which of the following is the most appropriate response by the nurse?
Using two forms of birth control may be effective against pregnancy, but this response does not
explain why one form must be a condom. Having both partners share responsibility for birth
control is a positive situation, but this is not the reason the client should use a condom along with
birth control pills. When used correctly, contraceptives are as effective in adolescents as in
adults. Condoms are the only birth control method that protect against sexually transmitted
diseases.
"You need to use two forms of birth control so if one fails you have a second form of protection
against pregnancy."
"Using a condom allows you to share the responsibility for birth control."
"Oral contraceptives are less than 99 percent effective in adolescents. Therefore, a second form
of contraception is needed."
"Oral contraceptives are highly effective in preventing pregnancy but do not prevent sexually
transmitted diseases."
40 A nurse is preparing to admit a 15-year-old client with HIV/AIDS. Based on the
client's diagnosis, which of the following nursing actions is appropriate?
HIV/AIDS is transmitted through blood and body fluids. The precautions necessary for blood
and body fluid transmission are standard precautions. The client and the client's family should
be educated regarding the transmission of infectious disease. Basic information about standard
precautions should be presented in a manner that is age-appropriate and considers educational
levels for the client and the client's family. The combination of hot water and detergents used in
hospital dishwashers is sufficient to decontaminate dishes, glasses and cups, and eating utensils.
Disposable dishes are not necessary. Airborne precautions require a negative pressure room.
Tuberculosis, not HIV, is a disease that would require this precaution. Visitors do not need to
wear either a gown or mask. A mask and gown are required during procedures and client
care activities that are likely to generate splashes or sprays of blood, body fluids, secretions,
or excretions to provide protection from contact transmission of pathogenic organisms.
Contribute to planning client education on standard precautions in age-appropriate manner.
Contact the dietary department to request foods be delivered on disposable dishes.
Prepare for infection control in a negative pressure room for this client.
Instruct visitors to wear gowns and masks when entering the client's room.
41 A nurse is reinforcing home care instructions with the parents of a 5-year-old child who has
acute bronchitis. In order to prevent the transmission of the virus, which of the following should
the nurse include in the instructions?
Acute bronchitis is generally caused by a virus. Transmission is via direct contact; therefore,
isolation is not required. Careful handwashing is important when caring for children with
respiratory infections. They should be taught to use a tissue to cover their nose and mouth when
they cough or sneeze and to wash their hands. Bronchitis is transmitted via articles contaminated
with nasopharyngeal secretions. The virus will not live if dishes are washed properly. The
combination of hot water and detergent is sufficient to decontaminate dishes, glasses, cups, and
eating utensils. Clients wear masks when they are immunocompromised and a health care
professional is trying to prevent the client from acquiring a secondary infection. A client with
bronchitis is not considered immunocompromised.
Isolate the child in a bedroom separated from the rest of the family.
Teach the child to wash his hands after coughing secretions into a tissue.
Serve food to the child on disposable dishes with plastic utensils.
Have the child wear a mask whenever leaving the bedroom.
42 A nurse is monitoring a 6-month-old infant who is diagnosed with pneumonia. The nurse
observes an absence of respirations and peripheral cyanosis. After determining
unresponsiveness, which of the following is the next nursing action?
This should be done after establishing an open airway. This is not the next nursing action.
Following cardiopulmonary resuscitation (CPR) techniques, the nurse should determine
unresponsiveness and reposition the infant to dislodge an obstruction or open the airway. For
infants, help is called after 1 min of CPR.
Look, listen, and feel for normal breathing.
Give two rescue breaths.
Position the infant to open the
airway. Immediately call for
assistance.
43 Which of the following emotional manifestations demonstrates an improvement in a 7-
month- oldinfant diagnosed with nonorganic failure to thrive?
The absence of separation anxiety and fear of strangers is a clinical manifestation of failure to
thrive. Most infants develop separation anxiety and fear of strangers from 6 to 8months of age.
Radar scan of the environment with a wide-eyed gaze is a clinical manifestation of failure to
thrive. Infants with nonorganic failure to thrive are detached and show less interest in social
interactions. Signs of nonorganic failure to thrive include the infant being passive, sleepy, and
lethargic. Infants with nonorganic failure to thrive do not like to be held or touched, so this
would be a sign of improvement.
Infant has no fear of strangers.
Infant scans environment with wide-eyed gaze.
Infant is passive and sleeps well.
Infant likes to be held and touched.
44 During an outpatient clinic visit a 13-year-old client is diagnosed with infectious
mononucleosis. The nurse should expect which of the following to be included in the
client's plan of care?
A simple nonnarcotic analgesic is usually sufficient to relieve the headache, fever, and malaise of
mononucleosis. Gargling alleviates the pain from sore throat. Warm water is soothing to the
inflamed throat and rinses the pharynx of secretions. Sometimes a short course of penicillin is
prescribed for sore throat, but ampicillin is contraindicated because it frequently triggers a
maculopapular rash. The child and family should be advised to limit exposure to persons outside
of the family, especially during the acute phase to prevent secondary infection.
Take acetaminophen (Tylenol) with codeine as prescribed for pain.
Encourage gargling with warm water to alleviate pain.
Start a short course of ampicillin.
Encourage social activity to prevent depression.
45 A nurse is reinforcing teaching with the parents of an infant diagnosed with recurrent
otitis media. Which of the following is appropriate teaching to include?
The use of steroids, decongestants, and antihistamines to treat acute otitis media is not
recommended. The upright position prevents formula from draining into the middle ear through
the eustachian tube. Equalizing tubes are used to treat otitis media, not tonsillectomy or an
adenoidectomy. These have not been found to be effective treatments. An ice compress placed
over the affected ear may provide comfort and reduce edema and pressure.
"Give the child an over-the-counter antihistamine when the symptoms begin."
"Hold the child in an upright position while feeding."
"Talk with the primary health care provider about performing a tonsillectomy."
"Apply a warm compress over the affected ear to provide comfort."
46 A nurse is caring for a child who has hemophilia. The nurse should expect abnormal results
in which of the following diagnostic tests?
Tests that measure serum fibrinogen level are all normal in persons with hemophilia.
Hemoglobin serves as the vehicle for transportation of oxygen and carbon dioxide. Itis not a
test that relates to the cause of hemophilia.PT measures prothrombin activity and bypasses the
intrinsic-extrinsic mechanism. It detects deficiencies in factor V, VII, X, and fibrinogen as well
as prothrombin. This laboratory test reveals that a client with hemophilia has prolonged PTT.
PTT measures the activity of thromboplastin, which depends on intrinsic clotting factors. Factor
VIII and IX are needed for the formation of thromboplastin, and it is factor VIII or IX that is
deficient in hemophilia or hemophilia B respectively.
Fibrinogen
Hemoglobin level
Prothrombin time (PT)
Partial thromboplastin time (PTT)
47 A nurse is caring for a 4-year-old child who is prescribed an intravenous
medication preoperatively. Which of the following therapeutic play techniques is most
appropriate when reinforcing the teaching for this procedure?
Role playing is best when it involves the child and enables the child to handle equipment. This
option has the nurse’s role playing with passive involvement of the child. Stories can be helpful
to introduce the topic; however, this does not diminish the anxiety of seeing the equipment for
the first time. Movies may scare a preschool child, especially if the child in the Movie cries
during the procedure. Allowing the child to see, hold, and collect the supplies familiarizes the
child with the frightening aspects of the procedure. Instruction can be based on the child's
questions in a nonthreatening environment. The child can gain an understanding of the
procedure by pretending to start an IV on a doll.
Role play with another nurse the technique of IV placement and how the medication is infused.
Read a story that explains the basics of how IVs are placed.
Watch a movie narrated by nurses and children about IV placement.
Explain the basic procedure and give the child IV supplies to play with, minus the needle.
48 A nurse is monitoring a child whose parents are suspected of child neglect. Which of
the following is an expected finding of neglect?
Physical neglect involves the deprivation of necessities such as clothing, food, shelter,
supervision, medical care, and education. Lack of parental education is not correlated with
physical neglect. Socioeconomic group is not a factor in child neglect. If the child is clean, faded
clothing with large shoes may be a sign of financial difficulties and not a sign of physical
neglect.
Lack of required immunizations
Parental lack of education
Lower socioeconomic group
Faded clothing with large shoes
49 A nurse is initiating a plan of care for a toddler who is hospitalized. Which of the
following instructions is important to communicate to the nursing assistant?
Toddlers are able to undress themselves, but do not have the fine motor development skills
required for dressing. Allowing the child to feed himself provides opportunities for autonomy
and motor skill development. Toddlers view everything in relation to self only and are involved
in parallel play. One way of dealing with negativism is to decrease opportunities for "no"
answers.
Have the toddler dress himself.
Offer the toddler finger foods for snacks.
Provide opportunities to share toys with others.
Ask the child simple yes or no questions.
50 A nurse is caring for a 3-year-old child with strabismus. Which of the following
actions should the nurse advise the parents to implement to help prevent amblyopia?
Biconcave lenses are used to correct myopia. While trauma should be avoided to prevent eye
damage, this is not an implementation to prevent amblyopia (impairment of vision or blindness)
from strabismus. Strabismus, or cross eye, is when one eye deviates from the point of fixation. If
the misalignment is constant, the weak eye becomes lazy and the brain eventually suppresses the
image. If not corrected by the age of 4 to 6 years, blindness from disuse or amblyopia may result.
Treatment includes covering the strong eye to strengthen the muscles in the weak eye. Dry eyes
are not a manifestation of strabismus.
Wear corrective biconcave
lenses. Prevent trauma to the
eyes.
Patch the strong eye.
Instill artificial tears.
51 A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of
the following nursing interventions is considered the priority?
Maintaining the infant's airway is of the highest priority. A child who is vomiting should be
positioned on the side or in a semi-reclining position to prevent aspiration. Administration of
fluids and electrolytes is important to prevent or correct dehydration and electrolyte imbalances,
but is not of the highest priority. Antiemetic medications are administered as prescribed if
necessary. This is not the first priority. Of major importance is avoiding ketosis. A dietary intake
high in carbohydrates spares the body protein and avoids ketosis which can result from
exhaustion of the glycogen stores. This is not the highest priority.
Place the infant in a side or semi-reclined position.
Administer oral rehydration and electrolyte
therapy. Administer antiemetic medications as
prescribed.
Maintain a high-carbohydrate intake to prevent ketosis.
52 A nurse has reinforced teaching to the parent of a 9-month-old infant who has redness in
the diaper area and inner thighs. Which of the following statements by the parent indicates a
correct understanding of this teaching
Hair dryers can burn the skin and thus are not recommended. Powder should not be used. It tends
to cake when the skin is wet, and there is also the danger of inhalation. Applying a skin cream
barrier is much more effective. Rubber pants should not be used because they do not allow air to
circulate. Thus, they promote skin irritation and breakdown. Exposing the skin allows it to air
dry completely which helps prevent breakdown.
"I can use a hair dryer on the reddened skin to help with the drying."
"I can use powder after diaper changes to absorb excess moisture."
"I can use cloth diapers with rubber outer pants until the rash clears."
"I can keep the diaper off to expose the skin to air."
53 A 6-year-old child is brought to the emergency department after falling down the outdoor
steps. The parent's account of the incident appears different than the neighbor's account of the
incident. Upon questioning the child, the nurse should recognize which of the following as usual
pattern of behavior exhibited by an abused child?
The child would answer questions but would not contradict the parent's story. The typical
reaction of the child is to repeat the same story as the parent. Children rarely betray the parent
even when the parent is abusive. The child will even defend the parent. While children have
creative imaginations, they do not make up stories in this scenario. Stress of the situation and the
fear of losing what security they have with the parent keeps children who have been abused
clinging to the parent's story. Children are afraid of losing the parent, so they do not implicate
the parent in the abusive behavior.
The child refuses to answer questions.
The child repeats the same story as the parent.
The child will fabricate an obviously false
story.
The child tells what really happened at the time.
54 A nurse is providing care for a 2-day-old neonate with a cleft lip and palate. The
nurse evaluates the parents' understanding of correct feeding methods. Which of the
following observations indicates a need for further teaching?
Large, soft nipples reach back further in the mouth. The large holes make sucking less of an
effort, and thus these types of devices appear to work well for nipple feedings after a cleft lip
and palate repair. When breastfeeding, the nipple is positioned back in the oral cavity so that the
action of the tongue can make the expression of milk easier. When an infant has trouble with a
nipple feeding, a rubber-tipped eye dropper makes feeding easier. The rubber tip extends the
length of the feeding device and has a larger hole so the infant doesn't have to create as much
suction. Infants with a cleft lip and palate have difficulty creating the suction required to get the
formula from the bottle. A "gravity flow" nipple with a squeezable bottle allows the formula to
be deposited directly into the mouth.
Uses a long, soft nipple with a cross-cut opening attached to a bottle
When breastfeeding, positions the nipple toward the front of the mouth
Uses an eyedropper with a piece of rubber tubing on the tip
Obtains a "gravity flow" nipple and attaches it to a squeezable plastic bottle
55 A nurse is holding an infant during a lumbar puncture for a suspicion of meningitis. The
infant is in a sitting position with the buttocks at the edge of the table and the neck flexed, and
the nurses is immobilizing the infant's arms and legs. Which assessment takes priority during the
procedure?
This is important to note anytime a spinal tap is done, but it is not the priority assessment. This is
important to note anytime a spinal tap is done, but it is not the priority assessment. Based on the
child's position, the nurse should be concerned about limiting chest expansion and movement of
the diaphragm. Based on the bending of the neck, the nurse should be concerned about the
infant's soft, pliable trachea, which may collapse. This is important to note anytime a spinal tap
is done, but it is not the priority assessment.
Circulation checks of the lower extremities
Heart rate and crying pattern
Chest expansion and diaphragm excursion
Clarity of spinal fluid and level of consciousness
56 A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a
high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked
lips.
Which of the following should the nurse tell the parent?
This is contraindicated because this diet has little nutritional value (it is low in energy and
protein) and is high in carbohydrates and low in electrolytes. These soups contain excessive
sodium and inadequate carbohydrates. Infants and children with acute diarrhea and dehydration
should be treated first with oral rehydration solutions. These help the child replace the sodium
and water that are being lost through the vomiting. Water has no electrolytes and will not help
compensate for the diarrhea and dehydration.
"Give the infant applesauce and rice cereal because these have been found to have high
nutritional value."
"Encourage the child to take sips of chicken or beef broth because they will replace the fluid
losses your child is experiencing."
"Give the infant oral rehydration solutions that are available commercially. They replace some of
the electrolytes lost through vomiting."
"Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce
sips of clear water."
57 A nurse is caring for a 4-year-old client with full-thickness burns. Which of the
following nursing actions are essential for the care of this child? (Select all that apply.)
Monitor level of consciousness is correct. Symptoms of confusion or seizures can result from
alterations in the electrolyte balance. Disorientation is one of the first signs of sepsis or may
indicate inadequate hydration. Maintain intravenous fluids is correct. Fluid shifts that occur after
a burn injury make intravenous fluids very important. Intravenous fluid therapy compensates for
loss of water and sodium, reestablishes electrolyte balance, and corrects acidosis. IV therapy
restores circulating volume, provides sufficient perfusion, and improves renal function.
Document vital signs is correct. Management of pulmonary and cardiovascular status is apriority,
especially in the acute phase of burn injury treatment. The respiratory system is monitored for
burn involvement and if suspected or evident, then 100% oxygen is administered. An
endotracheal tube may need to be inserted to maintain the airway. Blood gas values including
carbon monoxide levels are obtained. Heart rate helps to determine the adequacy of fluid
resuscitation.
Provide a low-calorie, high carbohydrate diet is incorrect. Clients who have suffered
burns should have a high-protein, high-calorie diet. This helps to avoid protein breakdown
as the body's metabolism increases after a burn injury.
Monitor urinary output is correct. Urinary output helps to determine the adequacy of fluid
resuscitation. Urine output and specific gravity help to establish adequate hydration and guide
the rate of fluid administration.
Administer morphine subcutaneously for pain is incorrect. Morphine sulfate is the preferred
medication for severe burn injuries. It is administered continuously by IV infusion. The unstable
circulatory status, edema, and tissue damage make intramuscular and subcutaneous injections
contraindicated in burn injuries.
Monitor level of consciousness is correct. Symptoms of confusion or seizures can result from
alterations in the electrolyte balance. Disorientation is one of the first signs of sepsis or may
indicate inadequate hydration.
Maintain intravenous fluids is correct. Fluid shifts that occur after a burn injury make
intravenous fluids very important. Intravenous fluid therapy compensates for loss of water and
sodium, reestablishes electrolyte balance, and corrects acidosis. IV therapy restores circulating
volume, provides sufficient perfusion, and improves renal function.
Document vital signs is correct. Management of pulmonary and cardiovascular status is a
priority, especially in the acute phase of burn injury treatment. The respiratory system is
monitored for burn involvement and if suspected or evident, then 100% oxygen is administered.
An endotracheal tube may need to be inserted to maintain the airway. Blood gas values
including carbon monoxide levels are obtained. Heart rate helps to determine the adequacy of
fluid resuscitation.
Provide a low-calorie, high carbohydrate diet is incorrect. Clients who have suffered
burns should have a high-protein, high-calorie diet. This helps to avoid protein breakdown
as the body's metabolism increases after a burn injury.
Monitor urinary output is correct. Urinary output helps to determine the adequacy of fluid
resuscitation. Urine output and specific gravity help to establish adequate hydration and guide
the rate of fluid administration.
Administer morphine subcutaneously for pain is incorrect. Morphine sulfate is the preferred
medication for severe burn injuries. It is administered continuously by IV infusion. The unstable
circulatory status, edema, and tissue damage make intramuscular and subcutaneous injections
contraindicated in burn injuries.
Monitor level of consciousness.
Maintain intravenous fluids.
Document vital signs.
Provide a low-calorie, high-carbohydrate diet.
Monitor urinary output.
Administer morphine subcutaneously for pain.
58 A nurse is caring for a 7-month-old infant with acute bronchiolitis. The infant has a
persistent, dry, hacking cough that worsens at night, tachypnea, and weakness. Which of the
following actions should the nurse implement?
Cough suppressants may be useful to allow rest but can interfere with clearance of secretions.
They have not proven to be of benefit for this condition. Bronchiolitis is caused by a virus and is
transmitted via direct contact. Therefore, contact precautions are required rather than droplet
precautions. Antibodies and corticosteroids are not effective in uncomplicated bronchiolitis.
Fluids by mouth may be contraindicated to prevent aspiration if the child has tachypnea,
weakness, and fatigue. Therefore, IV fluids are preferred to maintain hydration and dilute
secretions.
Administer prescribed cough suppressants as needed.
Place the child on droplet precautions.
Administer antibiotics and corticosteroids as prescribed.
Provide intravenous fluids as prescribed.
59 A nurse is caring for an infant with hypospadias. Which of the following is an
expected finding?
This defect describes epispadias, a condition in which the meatal/urethral opening is on the
dorsal/back surface of the penis. With hypospadias, the urethral opening can be anywhere on
the underside/ventral surface of the penile shaft or the perineum. Fluid in the scrotal sac is
referred to as hydrocele. testes that are not palpable within the scrotal sac are an indication of
cryptorchidism. This is a failure of one or both testes to descend through the inguinal canal.
The meatal opening is on the dorsal surface of the penis.
The urethral opening is on the underside of the penis.
Fluid is present in the scrotal sac containing the testes.
The testes are not palpable within the scrotal sac.
60 A nurse is caring for a 3-year-old child who is diagnosed with a urinary tract infection (UTI).
The parent is concerned about recognizing the signs and symptoms of future UTIs. Which of
the following statements made by the parent indicates a correct understanding of the
manifestations of a UTI?
A child who has frequent urination and exhibits strong-smelling urine should be evaluated for a
UTI. These are signs of glomerulonephritis, not UTI. These symptoms are seen in acute renal
failure and are not signs of a UTI. Hematuria, not abdominal pain, is a sign of a UTI.
"I should look for more frequent urination and strong-smelling urine."
"My child would have tea-colored urine and puffiness around the eyes."
"I should observe for episodes of nausea and less frequent urination."
"My child would have pale-colored urine and abdominal tenderness and pain."
ATI.CHILD CARE 1.0
1 A child diagnosed with asthma begins corticosteroid treatments. The nurse explains to
the parents that the purpose of corticosteroid treatment is to produce which therapeutic
effect?
Incorrect: Dilation of the bronchial airways is common in treating asthma. Albuterol is a
common medication.
Incorrect: Bronchospasms are usually reduced by B-2 agonists and bronchodilators.
Incorrect: Infections are treated by antibiotics but not indicated in the treatment of asthma unless
lung congestion is noted.
Correct: Corticosteroid usage is common for decreasing inflammation of the bronchial
airways.
Dilation of bronchial airways
Decrease bronchospasms
Prevention of infection
Anti-inflammatory effect
2 Which is the recommended treatment for moderate to severe lead poisoning?
Incorrect: IV fluids are typically not used in the treatment of lead poisoning. IV fluids area
conservative treatment regimen and are not indicated for treatment of lead poisoning; a more
radical therapy is needed to remove the lead from the body.
Incorrect: Treatment with antiemetic is not effective in the treatment of lead toxicity because the
heavy metal is absorbed into the body. Lead ingestion usually occurs more than one time.
Correct: The heavy metal antagonist, edetate calcium disodium, is frequently the drug of
choice for the removal of the lead toxin from the body. Chelating agents inactivate the
toxicity of the lead and cause excretion through the urine. Others drugs may treat the
symptoms of toxicity rather than remove the lead from the body. Untreated lead toxicity
can lead to a wide array of neurobehavioral problems include: attention deficit-
hyperactivity disorder, reduced cognitive performance, irritability or lethargy,
aggressiveness, and hearing impairment. The most serious and irreversible side effect of
lead poisoning is encephalopathy, which is associated with lead levels > 100 mg/ dL.
Incorrect: Antibiotics have no effect on the removal of the
toxin. IV fluids
Antiemetics
Heavy metal antagonist
Antibiotics
3 Which treatment is a nursing priority when providing care for an infant diagnosed
with bacterial meningitis?
Incorrect: Cardiorespiratory monitoring is standard for care of the child with bacterial meningitis
as a means of establishing the baseline parameters for vital signs. The infant with meningitis may
have a low baseline heart rate, tachypnea or fever. This however, is not the priority nursing
intervention.
Incorrect: The initiation of IV fluids for hydration and nutrition is a primary concern for the care
of the infant with bacterial meningitis. However, the most important intervention is starting
antibiotic therapy.
Incorrect: Meningococcal meningitis is the only type of meningitis spread through air-born
droplets and therefore, respiratory precautions need to be initiated as soon as possible.
Respiratory isolation is important for the control of transmission of the disease after the child
receives the first doses of antibiotics.
Correct: The first nursing priority is the implementation of antibiotic therapy, which
prohibits the microbial damage to the neurologic system through the cerebral spinal fluid.
Bacterial meningitis has a high rate of infant morbidity (illness) or mortality (death).
Immediate treatment with antibiotics can prevent: death, deafness, reduced cognitive
ability, attention deficit-hyperactive disorder, seizures and various other complications.
Initiate cardiorespiratory monitoring.
Initiate intravenous fluids.
Observe respiratory isolation.
Administer antibiotic
therapy.
4 The dosage of a pediatric medication is 120mg/kg/day to be give t.i.d. The patient weighs
12 pounds. What is the correct dose for the nurse to administer?
Incorrect: The dose of 120 mg is half the indicated dose. The erred dosage represents a failure to
divide the total daily dose by the number of individual dosages required per day. The failure to
use the weight in the calculation is evident.
Incorrect: The dosage of 480 mg is an excessive dose for the child. The calculation error is likely
a failure to convert pounds to kilograms.
Correct: The patient weighs twelve pounds. This weight converts to kilograms by dividing
12 by 2.2 (1 kg. = 2.2 lb.). In this example, the child's weight converts to 5.4 kg. The daily
dose of 120 mg is given t.i.d: each individual dose is 40 mg/kg. Then multiply the weight in
kilograms by the individual dose (40mg). The individual dose is 218 mg.
Incorrect: The dose of 650 mg is too large of a dose. The weight of the child when converting
from pounds to kilograms is 5.45 kg. The dose is ordered to be given t.i.d.. Therefore, the daily
dose of 120 mg/kg/day is divided by 3 to yield an individual dose of 40 mg/kg/dose. The error is
this dosage was likely a failure to divide the total daily dose by the number of doses required per
day.
120 mg
480 mg
218 mg
651 mg
5 In a child diagnosed with Tetralogy of Fallot, which of the following is a
compensatory mechanism to decrease venous return to the heart?
Correct: Squatting is a compensatory mechanism that decreases venous return
(deoxygenated blood) to the heart. The clinical sign is commonly seen in young children
with Tetralogy of Fallot (a type of cyanotic heart disease). The signs associated with
cyanotic heart disease include hypoxia, poor growth, low tolerance for physical exertion,
cardiomegaly, murmur and acute, intermittent blue spells that occur after crying or
feeding (tet spells).
Incorrect: Clubbing is found in children with chronic respiratory disease and cyanotic heart
disease. However, this finding is rare in young children.
Incorrect: Shortness of breath, retractions and increased respiratory effort occur with lung
dysfunction. Generally, the child with impaired oxygenation due to a cardiac lesion does not
exhibit signs of respiratory distress.
Incorrect: Polycythemia is common in children with hypoxia due to respiratory or cardiac
dysfunction. This compensatory mechanism increases the oxygen-. carrying capacity in the body.
The effect is not related to the venous return of unoxygenated blood to the heart.
Squatting
Clubbing
Shortness of breath
Polycythemia
6 A 1-year-old receives routine health maintenance care at the pediatric clinic. The child
receives an MMR immunization. The mother asks the nurse, "When will my child get the next
dose of MMR vaccine?" Which is the correct response by the nurse?
Incorrect: The DPT vaccine is routinely given in six months.
Incorrect: An additional dose of MMR vaccine is needed in the middle school years to maintain
full immunity from the diseases.
Incorrect: The first dose of Hepatitis B vaccine (HBV) is given in the hospital prior to discharge
home. A follow-up HBV is given in 1-2 months and followed up in 6-12 months following the
second does. The schedule does not coordinate with the routine immunization schedule for
MMR.
Correct: A second MMR, often called a booster, will be needed when the child enters
middle school at age eleven or twelve years of age.
In six months with the next DPT
No further vaccination needed
With the Hepatitis B series
After the child is 10 years of age
7 Which is a major difference in the clinical manifestation of adolescents with anorexia
nervosa compared to bulimia?
Incorrect: Binge eating is a common manifestation of both disorders.
Incorrect: Purging can be associated with both disorders.
Correct: The major difference between adolescents with anorexia nervosa and adolescents
with bulimia is body image distortion. Clients with anorexia see themselves as being
overweight no matter how underweight they become. Clients with bulimia see their weight
realistically but have psychological problems that manifest in an eating disorder.
Incorrect: Decreased self-esteem is often a catalyst of both disorders.
Binge eating
Purging
Body image distortion
Decreased self esteem
8 Which is the most common factor associated with non-organic failure to thrive?
Incorrect: A cool, drafty sleeping area is not a comfortable environment for sleep, but is
unrelated as a cause of failure to thrive.
Correct: The most significant factor associated with non-organic failure to thrive is
typically a disturbance in the mother/child relationship. A situation involving
dysfunctional family relationships is often complex; characterized by marital discord,
economic pressures, and parental immaturity with a low stress tolerance.
Incorrect: Lack of interest in the surroundings is a symptom of failure to thrive but not an
etiologic factor.
Incorrect: The financial hardship related to the expense of infant formula is not usually a primary
cause of non-organic failure to thrive. The Women's Infant and Children program (WIC)
provides infant formula at a low or no cost with eligibility. Therefore, the disorder is not likely to
be related to obtaining adequate nutrition but instead related to the ability of the infant to
consume, digest, and utilize the nutritive source.
A cool, drafty area for sleeping
Disturbance of mother/child relationship
Lack of interest in the surroundings
Financial hardship causing poor nutritional care
9 An adolescent recovering from substance abuse is diagnosed with hepatitis B. Which
nursing instruction should be included when planning the client's care?
Incorrect: During periods of acute hepatitis, the client needs plenty of rest.
Correct: The mode of the transmission in hepatitis B is via the parenteral route through
blood products, intravenous injection and maternal-fetal trans placental transmission. It is
extremely important for the nurse to educate the family about the relationship between
intravenous exposure and the transmission of the disease.
Incorrect: Fluid intake is not limited in the treatment of hepatitis B.
Incorrect: Eating a diet high in fat is contraindicated because of the liver involvement.
Increase exercise.
Avoid sharing
needles. Limit fluid
intake.
Eat a diet high in fat.
10 Changes in the growth and development of the preschooler are characterized by:
Incorrect: Continued rapid physical growth is not common for this developmental level.
Incorrect: Major changes in weight, height and head circumference have usually already taken
place prior to this developmental level.
Correct: Physical growth slows in the preschool years. Preschoolers enjoy social contacts.
Preschoolers are gaining control of their muscles and participate in vigorous activities with
other children.
Incorrect: Improvement in motor ability is rapid at this developmental level as the children are
gaining control of their muscles.
Preschoolers' gait resembles that of an adult.
Rapid physical growth and a persistent
curiosity.
Major changes in weight, height and head circumference.
A slowing of physical growth and expansion of social
contacts. A slow improvement in motor ability.
11 A teacher asks the school nurse to assess the behavior of a child with attention
deficit- hyperactivity disorder (ADHD). Which situation best facilitates an effective
nurse/child interaction?
Incorrect: Playground time for the discussion is desirable because the child would not miss
classroom instruction. However, recess is an appropriate time for the child to expel energy.The
playground offers many opportunities for distraction and the child may have difficulty
concentrating on the discussion in this environment.
Incorrect: A discussion between the nurse and student in the classroom would be brief and
impersonal due to the presence of other students. At the end of the day, this environment is
noisy, chaotic and rushed and may be one of the least desirable locations for a meaningful
dialogue between the nurse and student. The child will most likely be distracted.
Correct: A characteristic of attention deficit-hyperactivity disorder is distractibility and
impulsivity. A quiet and calm environment is necessary to engage the child in focused
discussion.
Incorrect: Although a physical education class provides the structured environment for the
release of energy in an appropriate manner, this is not a place for the nurse to provide education
to the child with ADHD. This setting also lacks the privacy necessary for a confidential
exchange of information.
Playground during recess
In the classroom at the end of the day
Nurse's office before school
Physical education class
12 The health care provider orders 60% oxygen to be administered with a partial rebreather mask
and bag reservoir. Which error regarding the oxygen delivery system requires correction?
Incorrect: Moisture collecting in the mask is the result of humidification of the air. Oxygen can
be very drying to the tissue and alveoli; damage can result to the airways without
humidification.
Incorrect: To optimize the delivery of oxygen via mask, a snug head strap is necessary.
Incorrect: The mask covering the nose and mouth is a correct application of the mask.
Correct: The reservoir bag on the non-rebreather mask should remain partially filled
during inspiration to provide positive end expiratory pressure (PEEP). If the bag collapses
the equipment may be faulty.
Moisture collects inside the mask
The strap around the head is snug
The mask covers the nose and mouth
The reservoir bag collapses during inspiration
13 A toddler is admitted to the hospital for treatment of acute gastroenteritis and dehydration.
The mother states that she must go home to make arrangements for the care of her other children.
To reduce the child's separation anxiety, which nursing intervention is most appropriate?
Incorrect: Placing the child in the crib may make the child feel more alone and afraid. At this
developmental stage, the child is not likely to be comfortable enough with the surroundings to
adjust and begin to play.
Correct: Anxiety is the child's predominant emotion with the separation from a parent.
Activities that calm and comfort the child are appropriate. Often a toddler will fall asleep
in the nurse's arms due to the stress of a parent's leaving the child alone in the hospital.
Incorrect: The video may serve as a distraction, but does not provide the security of human
contact.
Incorrect: The nurse's station may allow an opportunity for social contact. Many toddlers may be
overwhelmed or frightened by the activity at this central location.
Place the child in the crib with toys.
Rock the child in a rocking chair.
Turn on an age-appropriate video.
Take the child to the nurse's
station.
14 Which technique is most appropriate when assessing the circulation of a child's leg
in traction?
Incorrect: The movement of the toes is a neurological assessment and does not relate to
circulation.
Correct: The best way to assess circulation is to palpate the dorsalis pedal pulse located on
the top of the foot. If a peripheral pulse is not palpable, a Doppler may be necessary to
ascertain loss of circulation and pulse.
Incorrect: Assessing pain sensation in the lower extremities is a neurological assessment and
does not relate to circulation.
Incorrect: Range of motion to the affected area is usually contraindicated while in traction.
Determine if the child can wiggle the toes.
Palpate the dorsalis pedis artery.
Assess for pain sensation in the lower
extremity. Perform range of motion in the lower
extremity.
15 Initially, which solid food is generally recommended for an infant's diet?
Correct: Rice cereal is bland, easily digested and fortified with iron. Rice cereal is the first
food introduced into the diet at approximately six months.
Incorrect: Strained vegetables are introduced after the infant tolerates rice cereal. The order that
various foods are initiated is controversial and dependent on regional, generational, cultural and
personal factors.
Incorrect: Strained fruits are introduced generally after the infant tolerates strained vegetables.
Incorrect: Meats are introduced between 8-10 months of age. Infant meats are generally denser in
texture and less preferred by many infants. The coordination of the muscles of the tongue and
pharynx must be more developed for the introduction of solid meat.
Infant rice cereal
Strained vegetables
Strained fruits
Infant meats
16 A boy diagnosed with hemophilia falls while roller-blading and injures his knee. The nurse
is most likely to assess which physical finding?
Correct: Hemophilia is a group of bleeding disorders in which there is a deficiency of one
of the clotting factors. After a child sustains a traumatic injury to a joint, hemarthrosis is
likely to result. Incorrect: Thrombocytopenia, is a decreased number of platelets in the
circulating blood, and is not related to hemophilia.
Incorrect: Petechiae are pinpoint non-raised, purplish spots on the skin, which are characteristic
of low platelets.
Incorrect: Neutropenia, which is the diminished number of neutrophils, is not associated with
hemophilia.
Hemarthrosis
Thrombocytopenia
Petechiae
Neutropenia
17 A toddler is admitted to the emergency department following a febrile seizure.
Which information does the nurse provide to the family regarding febrile seizures?
Correct: There is little chance that future seizures will occur as a result of a febrile seizure.
Febrile seizures are the body's reaction to an immature thermoregulation system. This
reaction is not indicative of an epileptic disorder.
Incorrect: There is no familial tendency noted in febrile seizures.
Incorrect: Neurological defects are not commonly seen in children with febrile seizures.
Incorrect: Children who experience a febrile seizure are not at risk of developing a seizure
disorder.
There is no relationship to seizure disorders.
There must be a familial tendency toward seizures.
The child most likely has a neurological defect or brain
tumor. The child is likely to develop a seizure disorder as he
grows.
18 The nurse assesses Koplik spots on the lingual and buccal mucosa of a 4-year-old.
Which disease is likely to appear within the next two to three days?
Correct: Koplik spots are small red spots with bluish white centers on the lingual and
buccal mucosa. These spots are characteristic of an outbreak of measles. The measles rash
usually erupts a day or two after the appearance of the Koplik spots.
Incorrect: Mumps are an acute viral disease characterized by the swelling of the parotid glands.
Incorrect: Varicella virus (chickenpox) is a contagious viral disease characterized by vesicular
eruptions on the skin.
Incorrect: Pertussis is a highly contagious respiratory disease characterized by paroxysmal
coughing with dyspnea on inspiration.
Rubeola (measles)
Mumps (epidemic parotitis)
Varicella (chickenpox)
Pertussis (whooping cough)
19 Which is the most appropriate pain scale to use for a Spanish speaking 5-year-old child
who communicates very little in English?
Incorrect: The Poker Chip Tool uses four red poker chips to indicate the degree of pain. The child
must be able to count and have some concept of numbers for correct use of the tool.
Incorrect: The Eland Color Tool directs the child to use colored markers to fill in an outline of
the body with a color that describes their pain. This scale is used for children over four years of
age.
Correct: The FACES Pain Rating Scale is intended for use in the child ages 1-7 years. This
scale uses a pictorial face that represents the child's level of pain. The smile face indicates
that the child has no pain and the tearful face represents the highest level of pain. This
scale is useful to the non-English speaking child because words are not necessary for
reporting pain level.
Incorrect: The Word Graphic Rating Scale uses descriptive words to rate the intensity of pain
(no pain to worst possible pain) and aids the child in answering various questions about the
nature and degree of pain. It would not be appropriate for a child who speaks little English and
may not yet read.
Poker Chip Tool
Eland Color
Tool
FACES Pain Rating Scale
Word Graphic Rating
Scale
20 If a child with Type I diabetes mellitus takes regular insulin at 0800, which time during
the day should the parents be taught to expect the peak action of regular insulin?
Incorrect: At 0830 the onset, not the peak, of the regular insulin should be occurring.
Correct: Regular insulin peaks in two to four hours. The onset of the insulin begins in 30
minutes. A snack should be planned to avoid any symptoms of hypoglycemia.
Incorrect: At 1300 the peak time of the insulin has already
passed. Incorrect: At 1500 the peak effect of insulins achieved.
0830
1100
1300
1500
21 The nurse evaluates the effectiveness of care for the school-aged child with
juvenile rheumatoid arthritis (JRA). Which clinical outcome does the nurse expect the
child to demonstrate after nursing care interventions are implemented?
Incorrect: JRA is treated with non-steroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, aspirin, and naproxen, to reduce inflammation to the joints. Slower-acting
antirheumatic drugs may be added. Cytotoxic drugs are reserved for the child with severe,
debilitating disease. Antibiotics are not used for JRA.
Correct: The nurse observes the movements of the child and uses pain assessment tools to
determine the intensity of pain. Nonpharmacologic modalities and anti-inflammatory and
analgesic medication are provided to promote comfort and relieve pain associated with
JRA. By modifying pain perception, joint mobility is likely to improve with reduced
discomfort.
Incorrect: Children are encouraged to maximize their efforts for self-care and activities of daily
living. Exercise enhances the mobility and strength of the supporting muscles, which is
necessary in pain prevention. However, overexertion should be avoided.
Incorrect: Children with JRA, like many with chronic illness or disability, develop personality
traits including: manipulativeness, hostility, and passive aggressiveness. Although it is the goal
for care of the family to promote an understanding of the child's disease and altered lifestyle and
have compassion for the situation, it is important that family members do not enable the negative
behaviors to persist. Efforts need to be made to intervene early and prevent permanent
ineffective coping techniques.
The symptoms will subside with use of antibiotics.
The child is able to move with minimal or no discomfort.
The child limits his own physical activity to prevent pain.
The family copes with the child's manipulative behaviors.
22 The nurse providing care to the child with pediculosis capitus (head lice) educates the family
about the condition, transmission, and treatment. Which condition is necessary for survival of
the louse on the host?
Correct: Survival of the louse is dependent upon blood that is extracted from the host.
Incorrect: The louse feeds on the blood of the human host. Warmth is not necessary for survival.
Incorrect: The louse feeds on the blood of the human host. Moisture is not necessary for survival.
Incorrect: The louse feeds on the blood of the human host. Mucous is not necessary for survival.
Blood
Warmth
Moisture
Mucous
23 An adolescent with Type I diabetes mellitus asks her mother for permission to go with
friends to get pizza and ice cream. Which response by the adolescent's mother indicates that
previous nursing instruction has been effective?
Incorrect: It is not necessary to reinforce to the adolescent that he/she is unable to eat similar to
the friends. Peer groups and being accepted are very important at this age. The adolescent who
can manage the insulin needs in accordance with the diet is allowed to have a variety of foods.
Incorrect: It is not realistic or therapeutic to expect the friends to know the diabetic diet. This
type of expectation may alienate the child from the peer group. The adolescent typically values
the similarity to the peer group.
Incorrect: By avoiding the situation, the adolescent does not directly deal with the underlying
task of adapting the chronic illness into the lifestyle. An important part of developing
relationships among adolescents is spending leisure time together. The child alienates him or
herself and suppresses feelings of anger towards self, others and/or the disease.
Correct: The standard diabetic diet and appropriate nutritional education are flexible and
incorporates many preferred foods at various times. The dose of insulin will need to be
adjusted for this altered schedule, type and amount of food. Close glucose monitoring is
very important to the safety of the diabetic child whose metabolic needs are variable.
"It is important for you to spend time with friends but you cannot eat what they are eating."
"Your friends need to learn that there are certain foods that you cannot have. They will
understand that you can't go with them."
"You must stay away from those foods. It is easier for you to avoid the situation. You can go with
your friends another time."
"It is important for you to spend time with your friends. I will help you select your food and
determine your next insulin dose."
24 When obtaining a health history, which significant event may precede a diagnosis
of rheumatic fever?
Incorrect: Chickenpox is caused by varicella virus. Rheumatic fever is a complication of group A
beta hemolytic streptococcal pharyngitis.
Correct: There is evidence that rheumatic feverish associated with group A beta hemolytic
streptococci, which is a common cause of pharyngitis.
Incorrect: The presence of a heart murmur is not reason enough to diagnose rheumatic fever.
Rheumatic fever is associated with streptococcal infections.
Incorrect: Vomiting and diarrhea are frequently caused by intestinal viruses, not bacteria. The
primary symptoms of group A beta hemolytic streptococcal pharyngitis include: fever, malaise,
dysphagia, lymphadenopathy and occasionally diarrhea in the young child. Rheumatic fever is a
complication of “strep throat” that can cause cardiac damage.
Exposure to chickenpox
Recent severe sore throat
Presence of a heart murmur
Vomiting and diarrhea
25 Which intervention is most appropriate when providing nursing care for the child
diagnosed with Duchenne's muscular dystrophy?
Incorrect: Limitation of physical activity may accelerate the process of muscular deterioration
and atrophy.
Incorrect: Increased weight gain becomes more likely as the activity level diminishes. The care
of the child with a progressive, incapacitating disease becomes increasingly more demanding for
the caregivers at home. As a loss of mobility and independence occurs, the child will require
more lifting, dressing and physical care. Excessive weight would aggravate the situation.
Correct: The most important way for the nurse to impact the family of the child with
Duchenne's muscular dystrophy is to assist the child and family in coping with the
progressive, incapacitating and incurable disease. As muscular weakness progresses,
wasting and contractures develop. A loss of ambulance occurs usually be 9-11 years of age.
Difficult issues for the family to deal with pertain to loss of independence, mobility and self-
care and, eventually, death.
Incorrect: No effective pharmacologic treatment exists for Duchenne's muscular dystrophy.
Corticosteroid use has been reported beneficial in improving the muscle strength and size in
some children. However, there is no conclusive evidence that steroid use has palliative or
curative function. The goal for treatment is to maintain as much muscular function for as long as
possible.
Limit physical activity.
Increase caloric intake.
Assist the family to cope.
Administer steroids.
26 An adolescent comes to the clinic with a fever, sore throat, and fatigue. Physical assessment
findings reveal enlargement of the spleen and lymph nodes. Mononucleosis is diagnosed.
Which is the nurse's priority in planning the care for the child at home?
Correct: The patient with splenomegaly is cautioned to avoid heavy lifting, trauma to the
abdomen or vigorous athletics. Splenic rupture is a concern and requires immediate
attention. Incorrect: Limitation of visitors is important for the promotion of client rest,
however, isolation or visitor restriction is not needed.
Incorrect: Maintenance of adequate fluid volume is a concern but not a main priority. Bland cool
liquids that are not irritating to the throat are encouraged.
Incorrect: Due to the fatigue, getting plenty of rest is necessary but not the main priority for
instruction.
Avoid vigorous
athletics. Limit visitors.
Maintain adequate fluids.
Obtain plenty of rest.
27 The presence of which classic cell provides data for the definitive diagnosis of
Hodgkin's disease?
Correct: The Reed-Sternberg cell, which is seen on microscopic examination of lymph node
tissue, contains two nuclei and is diagnostic of the disease.
Incorrect: Sickling of the red blood cell is seen in sickle cell anemia, not Hodgkin's disease.
Incorrect: T-cells are not commonly elevated with autoimmunity diseases and not definitive for
the diagnosis of Hodgkin's
disease.
Incorrect: Epstein Barr is a virus and not related to Hodgkin's
disease. Reed-Sternberg cell
Sickle shaped red blood cell
Floating T-cell
Epstein Barr cell
28 Which is the most common complication of acetaminophen toxicity in the toddler?
Incorrect: Respiratory distress is not a complication related to acetaminophen toxicity. In the
latter stage, hepatic impairment, occurs which is characterized by jaundice, confusion and stupor,
pain in the upper right quadrant, and coagulation abnormalities.
Incorrect: Nausea and vomiting occur as a result of acetaminophen toxicity. Dehydration is
possible in the toddler with frequent vomiting and may be accompanied by electrolyte
disturbances.
Incorrect: Due to the metabolism of acetaminophen in the liver, the most common complication
is liver impairment.
Correct: Acetaminophen is metabolized in the liver, therefore, hepatic damage is a major
concern.
Respiratory distress
Fluid overload
Renal failure
Hepatic damage
29 During the acute phase of glomerulonephritis in a child, which intervention is the most
appropriate?
Incorrect: Although the child with acute glomerulonephritis is more susceptible to infection,
protective isolation procedures are not indicated. Careful handwashing and avoidance of known
or likely exposure to infectious organisms is reasonable and prudent.
Incorrect: During the oliguric phase of glomerulonephritis, the potassium intake should be
limited. The risk for hyperkalemia is increased if a high potassium intake accompanies decreased
urinary output and excretion of potassium.
Incorrect: Bedrest is often maintained in the acute phase. Children have malaise and fatigue with
glomerulonephritis and usually restrict their own activities. Although rest and sleep are
important, the most important intervention is focused on the prevention of serious complications,
such as malignant hypertension.
Correct: Neurologic complications, such as seizures and diminished level of consciousness
may occur because of severe hypertension associated with acute glomerulonephritis. The
child with edema, hypertension and gross hematuria may be subject to neurologic
complications.
Observe protective isolation procedures.
Encourage increased potassium intake.
Encourage bedrest with appropriate diversional
activity. Assess the child for signs of neurologic
complications.
30 An 18-year-old female diagnosed with systemic lupus erythematosus (SLE) comes to the
rheumatology clinic for a follow-up visit. The nurse assesses the client's skin and reviews
the client's BUN and creatinine levels. Which is the rationale for the nurse's actions?
Correct: SLE is a chronic inflammatory disease characterized by injury to the skin, joints,
kidneys, nervous system and mucous membranes. Clients often seek medical help for relief
of fever, weight loss, joint pain, butterfly rash, pleural effusion and nephritis. Because of
the kidney damage, the blood pressure will rise and protein in the urine may be evident.
Edema results.
Incorrect: Kidney damage is common, but does not result in dehydration or dry skin.
Incorrect: The characteristic rash in SLE is on the face, not generalized over the body, and is in
the shape of a butterfly.
Incorrect: Urinary frequency is not a characteristic of SLE. Instead hematuria and decreased
urine output are common.
A "butterfly rash" and kidney damage are common characteristics of the disease.
The client is prone to dry, scaly skin and dehydration related to kidney dysfunction.
The generalized rash may lead to a secondary infection affecting the kidneys.
The disease process is complicated by urinary frequency and a papular rash.
31 At an unscheduled clinic appointment, the mother of a 9-month-old states that she is
concerned about her baby's small size and frequent crying. The mother has limited support
systems and poor role modeling for parenthood from her own childhood. Which initial
physical assessment data is most important for the nurse to obtain at this time?
Incorrect: The measurement of head and chest circumference can provide data indicating the
presence of hydrocephalus, microcephaly or neurological defects. Although these growth
parameters also indicate the patterns of growth, the height and weight are more specific measures
of overall growth.
Incorrect: Heart rate and breath sounds are important measures for the physical assessment of the
cardiorespiratory status but do not indicate growth patterns.
Correct: Excessive crying may indicate a wide variety of physical or emotional problems
in infancy. The nurse who suspects that the infant is failing to thrive in the home
environment first obtains the data regarding the infant's pattern of growth: the height and
weight.
Incorrect: The suck reflex, present at birth, is vital for infant nutrition. By nine months of age,
however, the child should be eating solid foods, chewing soft foods and teething. The
assessment for presence of the suck reflex is most appropriate during the newborn assessment.
Chest and head circumference
Heart rate and breathe sounds
Height and weight
Sucking reflex
32 Which information regarding suspected episodes of child abuse should the nurse include in
the documentation?
Incorrect: Summative statements regarding the events of potential child maltreatment or sexual
abuse are inappropriate. Direct quotes from interviewees are recommended to reduce bias and
premature judgment.
Correct: The documentation of events related to potential child abuse needs to be an
objective, factual and concise. Direct quotations from interviewees are recommended to
reduce personal bias, interpretation or judgment.
Incorrect: Generalizations regarding the nature of actions leading to harm in a child are
inappropriate. Clear, concise, and concrete information is absolutely necessary for the
documentation of the events in question.
Incorrect: Interpretative statements do not have an appropriate role in the delivery of care to the
child with suspected maltreatment or sexual abuse. When allegations are made regarding the
actions leading to harm to a child, clear, concise and factual information needs to be documented.
Summative statements
Exact quotes regarding the events
Generalized description of events
Statements related to causative factors
33 A toddler is diagnosed with impetigo and the nurse gives the toddler's mother
instructions about skin care. Which statement by the mother indicates a need for further
education?
Incorrect: The transmission of impetigo occurs from direct contact with infected skin
surfaces. The disease is highly contagious.
Incorrect: Impetigo contagious is highly communicable in the toddler and preschool child. The
skin is colonized with staphylococcal organisms that cause impetigo and therefore, toddlers and
preschoolers are susceptible to bacterial infections from their own skin.
Correct: Impetigo is a staphylococcal infection that is highly contagious. The impetigo
lesions should be cleaned three to four times a day with Burrow's solution 1:20 to remove
the crusts. Usually, the application of a topical bactericidal ointment (Bactroban) follows
the wound debridement. With proper wound care, lesions are not likely to scar unless a
secondary infection occurs.
Incorrect: Cleaning the lesions three to four times daily is a correct treatment regimen.
"Impetigo can be spread from one body surface to another."
"Toddlers are susceptible from the bacteria on their own skin."
"The crusted areas should be allowed to fall off without
treatment." "The lesions need to be cleaned three to four times
daily."
34 The nurse provides nutritional education for the mother of a toddler. Which information in
the toddler's health history indicates a problem regarding nutrition? The toddler:
Incorrect: The developmental stage of a toddler is often characterized by ritualistic behavior
regarding many daily routines, including mealtime. The toddler in his effort to control the
environment and create a predictable and secure life may insist on various details regarding the
meal.
Incorrect: Playing with food and dishes is a normal developmental finding for toddlers.
Toddlers do eat some of the food they play with. Therefore, foods should be nutritious and
appropriate for the age group. Incorrect: Imitating eating patterns of others is a normal finding
for toddlers.
Correct: The variety and volume of food in a toddler's diet is increased and the volume of
milk is lessened. Cow's milk contains little iron and displaces the hunger for solid foods.
The most common cause of iron deficiency anemia is related to excess cow's milk in the
diet.
is particular about the arrangement of food on the plate.
likes to play with the food and dishes.
imitates the eating habits of an older sibling.
drinks 42 ounces of cow's milk per day.
35 During the mental health examination of a troubled teen, the nurse assesses for the risk of
violence. Which nursing response is most appropriate?
Correct: Safety for the teen is important. By asking a direct question, the youth can
verbalize feelings instead of acting out the behavior against oneself or others.
Incorrect: Asking a question about the past does not focus on the problems in the present. This
question does not address violent behavior currently.
Incorrect: Discussing impulse control is important but does not address suicidal or homicidal
behavior that is at risk with violent teens.
Incorrect: While family patterns are often passed from generation to generation, the priority is
focusing on the client’s violent behavior and not the family's pattern of behavior.
"Do you feel like hurting yourself or anyone else?"
"Have you responded to stress with aggressive behavior in the past?"
"Have you ever had a problem with impulse control?"
"Tell me how your family deals with anger."
36 A physician orders gentamicin (Garamycin) one drop OS four times daily for a 3-year-
old child. Which method of medication administration is most appropriate?
Incorrect: Instilling drops into the right eye is incorrect as the doctor ordered the drops be
instilled into the left eye. OD is the abbreviation for right eye.
Correct: OS is the correct abbreviation for the left eye. The appropriate procedure is to pull the
left lower eyelid down forming a cradle and then instilling the drop.
Incorrect: Pulling down the pinna of the ear is not inappropriate technique for instilling eye
drops.
Incorrect: Pulling the pinna of the ear upward is not the appropriate procedure for instilling eye
drops.
Pull the right lower eyelid down, instill drops, and then repeat with the other eye.
Pull the left lower eyelid down, forming a cradle, and instill the drops.
Pull the left pinna down and back to instill the drops.
Pull the right pinna upward and back and instill the drops.
37 A school-age client receives a blood transfusion. The nurse assesses shortness of
breath, bulging neck veins, and a moist cough. These findings are indicative of which
complication?
Incorrect: An allergic reaction has signs and symptoms of urticaria, flushing, wheezing and
laryngeal edema.
Correct: The findings of shortness of breath, neck vein bulging and a moist cough indicate
fluid overload.
Incorrect: An air embolism would present with symptoms of difficulty breathing, a sharp pain in
the chest and apprehension.
Incorrect: A hemolytic reaction may present with symptoms of chills, fever, nausea/vomiting,
headache, pain in the chest, not dyspnea, and moist cough.
An allergic reaction
Fluid overload
An air embolism
A hemolytic reaction
38 The nurse plans the preoperative care of the infant with pyloric stenosis. In feeding the
infant, which measure should be implemented until surgery?
Incorrect: An increase in the frequency and amount of the feedings will increase the volume of
the stomach, which is already having difficulty emptying, resulting in overload within the
stomach. Projectile vomiting is a common symptom.
Incorrect: Burping any infant is important. The infant with pyloric stenosis is not burped any
more frequently than any other infant. Care is taken that the infant is handled gently during the
burping.
Incorrect: The Breck feeder is used for infants with cleft lip and palate.
Correct: Pyloric stenosis is a narrowing of the pyloric sphincter at the outlet of the
stomach. The infant should be allowed to rest after the feeding. Handling the infant should
be kept to a minimum so the feeding can advance down the digestive tract.
Increase the frequency of the feedings.
Burp the infant between feedings.
Feed the infant with a Breck
feeder. Let the infant rest after the
feeding.
39 When providing instructions to a day care provider about the transmission of chickenpox,
which statement by the day-care worker reflects a need for further education about the infectious
phase of this disease?
Incorrect: Varicella virus is transmitted through the respiratory route in the droplet form.
Incorrect: Varicella virus is transmitted through direct or indirect contact.
Correct: Chickenpox is a highly contagious disease caused by a primary infection with
varicella-zoster virus. The characteristic feature is the generalized, vesicular rash that
itches. The mode of transmission is direct contact with persons infected with the varicella
and herpes zoster viruses. Respiratory spread by droplet also occurs. The disease is most
contagious in the incubation period prior to or including the time of onset of prodromal
symptoms and the first crop of the rash. The lesion dries and the crust falls off within 5 to
20 days. By the time the lesions scab over, children are no longer infectious and may
return to the daycare setting. Seizures are not associated with chickenpox.
Incorrect: Varicella lesions with drainage are contagious; the child should remain at home until
all vesicles have dried and crusted. Immunosuppresses persons should not be exposed to the
virus.
"Chickenpox is spread through the respiratory tract."
"Chickenpox is transmitted by direct contact."
"When the rash first appears, we should watch for seizures."
"Children that have seeping pox should remain at home."
40 Digoxin (Lanoxin) is used in the treatment of a client diagnosed with a congenital
heart defect. Which is the mechanism of action?
Incorrect: The mechanism of action for digoxin is increased cardiac contractility. Nitroglycerine,
not digoxin, is an example of a cardiac medication that is used primarily for the effect of
vasodilation of the coronary arteries.
Correct: Digoxin is used to increase the contractility of the heart and improve the cardiac
output. By increasing the effectiveness of the heart's pumping action, the blood supply to
the body is improved. The increased tissue perfusion leads to improved oxygen delivery to
the organ sites.
Incorrect: Digoxin is primarily used to increase the cardiac output by improving the contractility
of the heart.
Incorrect: A diuretic is often used for congestive heart failure to reduce systemic overload
associated with congenital heart defects.
Dilates the coronary arteries
Improves contractility of the heart
Reduces venous return to the heart
Decreases systemic overload
41 The nurse provides care for the child diagnosed with glomerulonephritis and collects a
urine sample for urinalysis. Which urine color suggests the presence of red blood cells?
Correct: The presence of blood in the urine gives the urine a smoky color.
Incorrect: A cloudy appearance is commonly associated with the presence of white blood cells.
Incorrect: Bright orange urine occurs as a result of the administration of phenazopyridine
hydrochloride (Pyridium). This medication reduces the symptomatic relief or urinary burning,
itching, frequency and urgency with urinary tract infection or following urologic procedures.
This medication stains clothing.
Incorrect: Dark yellow urine is an indication of concentrated urine with a high specific gravity.
Smoky
Cloudy
Bright orange
Dark yellow
42 A 2-month-old baby is diagnosed with cystic fibrosis. Which statement most
accurately defines this disorder?
Incorrect: Cystic fibrosis is not a dominant disorder and does not lead to fatty deposits on the
liver.
Incorrect: Cystic fibrosis is not linked on a dominant gene and is not produced by the lungs.
Incorrect: Structural changes of the heart are not produced by cystic fibrosis.
Correct: Cystic fibrosis is a recessive disorder that is inherited from both parents. Cystic
fibrosis is a disorder of the exocrine glands causing the glands to produce abnormally thick
mucus secretions. The glands most affected are those in the pancreas, respiratory system
and sweat glands.
Dominant disorder in which an enzyme deficiency leads to fatty deposits on the liver
Dominant disorder in which secretions produced in the lungs plug the airway and induce
respiratory distress
Recessive disorder in which structural changes occur in the heart muscle
Recessive disorder in which abnormal amounts of secretions are produced by the exocrine glands
43 Initial treatment for unilateral (talipes equinus) clubfoot includes which intervention?
Incorrect: Passive range of motion may be used in later stages of healing but is not the initial
treatment.
Correct: Casting is implemented as soon as the diagnosis is made. The cast is changed
regularly as the child grows.
Incorrect: A soft brace is used to add support to an extremity but does not change the true
alignment.
Incorrect: The hip spica cast is used for congenital dysplasia of the hip and not for clubfoot.
Passive range of motion exercises to the ankle and toes four times daily
Application of a cast to the affected foot as soon as diagnosis is
made A soft brace to hold the foot in the proper alignment until
surgery The use of a spica cast until the newborn is ready for surgery
44 A 10-year-old is seen in the allergy clinic. The child describes itchy, watery eyes and nasal
congestion after spending time outdoors. The skin is noted to be dry and scaly in patches on the
back of the arms. Skin testing is ordered. Which measure by the nurse promotes the accuracy
of the testing?
Incorrect: Skin testing is commonly repeated with different variations of allergens included. It is
still important to note past sensitivities on past medical histories, but the use of antihistamines
are still more important for the test accuracy.
Incorrect: Assessment of lung fields and nasal mucosa is a precautionary measure. This indicates
a reaction to past allergens and could be enhanced following the skin testing.
Correct: Antihistamine use suppresses skin test reactivity and should be withheld for five
days prior to testing.
Incorrect: The upper forearm and upper back, not the abdomen, are appropriate sites for allergy
testing. Determining a site depends upon the location of choice, cooperation of child and
specifics of skin.
Assessing past medical history for skin testing that was previously positive
Assessing the lung fields for wheezing and nasal mucosa for irritation
Reviewing medications over the past five days for antihistamine use
Using the child's abdomen instead of upper forearm for skin testing
45 A school-age child falls from a bicycle and sustains head trauma. Upon arrival to the
emergency department, the nurse identifies signs indicating increased intracranial
pressure. Which sign should the nurse document?
Incorrect: A rapid response of the pupils to light is an appropriate neurological response. Pupils
that are fixed and dilated or sluggish to react to light and accommodation indicate increased
intracranial pressure. Retinal hemorrhages and papilledema occur with brain injury.
Incorrect: Widened pulse is the increased discrepancy between the systolic and diastolic blood
pressure. The pulse pressure typically widens with increased intracranial pressure. This isa
late finding, occurring more often in adults.
Incorrect: Elevated body temperature sometimes occurs as an indicator of increased intracranial
pressure.
Correct: Classic signs of increased intracranial pressure in the school-age child include:
altered mental status, agitation, vomiting without nausea, diplopia (double vision), elevated
body temperature and widened pulse pressure. The behavioral changes of a child are the
most reliable indicators of acute intracranial pressure change.
Rapid response of the pupils to light
Narrowed pulse pressure
Decrease in body temperature
Mounting agitation
46 According to Erikson's theory of child development, the normal school-aged child masters
which psychosocial stage for development of healthy personality?
Incorrect: Autonomy versus shame and doubt is Erikson's stage of psychosocial development
that occurs during the toddler period. The child learns of his or her ability to predictably control
own actions that also have a direct effect on the reaction and behavior of others. During
toddlerhood, areas of conflict regarding autonomy are typical. The toddler's will to control exists
with an immature lack of understanding about natural consequences to actions.
Incorrect: Identity versus role diffusion emerges during the pubescent period. A sense of group
identity precedes the development of personal identity. Adolescents first engage in mastering the
task of finding their place within the peer group prior to resolving issues relating towho they are
in relation to the inner self, family and society.
Incorrect: Initiative versus guilt is a psychosocial, developmental task of the preschool child.
Children at this age begin to play and learn about the world through their own endeavors. They
take pride in the new-found abilities to engage in new activities and produce some outcome. The
demands of a task for a preschool child may exceed the maturity or skills and produce some
degree of remorse, anxiety or guilt.
Correct: The child in the middle years develops a fundamental attitude toward work.
During this stage of accomplishment, the child master’s various skills that enable him/her
to participate in the family or community in a meaningful way. The child who is not
prepared or capable to accomplish or assume the responsibilities associated with the
stage of industry may develop a sense of inferiority
Autonomy versus shame and doubt
Identity versus role diffusion
Initiative versus guilt
Industry versus inferiority
47 A preschool child is brought to the primary-care clinic because of anal itching at night.
The child is diagnosed with pinworm infestation and mebendazole (Vermox) is prescribed.
Which instruction to the family is most important regarding follow-up care?
Incorrect: Washing the sheets in hot water is advised for hygiene measures. However, the control
of the infestation occurs with the pharmacologic treatment (Vermox).
Incorrect: Isolation of the child is unnecessary after treatment with Vermox. The first dose of
medication is highly effective in controlling the infestation.
Incorrect: Showering is recommended rather than tub-bathing during the two-week period
between the initial dose of Vermox and the follow-up dose. Other measures to prevent re-
infestation to the child or others include: thorough handwashing after toileting, keeping the
child's fingernails short to minimize the ova collecting under the nail, and dressing the child in
one piece sleep attire to minimize itching at night.
Correct: All family members are treated with one dose of the medication. After treatment
with the single Vermox dose, the pinworm infestation is eradicated. A second dose two
weeks after the initial therapy is necessary to prevent re-infestation.
All sheets must be washed in hot water.
Contact with other children should be avoided for 7-10 days.
Daily tub bathing is recommended during infestation.
The entire family must be treated with Vermox.
48 A nurse assesses the growth and development of a 3-month-old. Which activity
is undeveloped at this age?
Incorrect: Holding a rattle is an appropriate motor activity for a three-month old infant due to the
intact grasp reflex. The infant frequently drops a rattle because the grasp is reflexive and not
purposeful.
Incorrect: Attempting to roll over is an appropriate developmental function at three months of
age. The infant is beginning to coordinate the movements of the body.
Correct: The three-month old infant does not have the ability to use the pincher grasp.
Usually this fine motor skill occurs at about eight months of age.
Incorrect: Typically, smiling in response to a mother's voice and social behavior occurs at two
months of age.
Holds a rattle and places it in the mouth
Attempts to roll over
Picks up a small object using finger and thumb
Smiles in response to mother's voice
49 Which diagnostic procedure is used to ascertain if a female client has
gonorrhea? Incorrect: Blood specimens are not an indicator of gonorrhea.
Correct: The diagnostic test for gonorrhea is a vaginal culture with microscopic
examination.
Incorrect: Pus in the urine may be indicative of a urinary tract infection but not gonorrhea.
Incorrect: Determining the last menstrual period is not helpful with the diagnosis of gonorrhea.
Take a blood specimen.
Obtain a vaginal culture.
Test the urine for pus.
Determine the last menstrual period.
50 The nurse assesses the development of a 3-year-old child at a routine clinic visit. The
nurse should expect the mastery of which developmental task?
Correct: A three-year old child with normal development is able to identify five body parts.
Incorrect: The dexterity necessary to copy a square does not normally develop until six years of
age.
Incorrect: The fine motor skills that are necessary for tying shoelaces do not normally appear
until five or six years of age.
Incorrect: The school-aged child, not the preschooler, is normally able to hop on one foot.
Identifying five body parts
Copying a square
Tying shoelaces
Hopping on one foot
51 The nurse providing nutritional instruction to parents of a child diagnosed with cystic
fibrosis recommends which type of diet?
Correct: The child with cystic fibrosis lacks the pancreatic enzyme necessary for adequate
digestion and growth. A well-balanced, high-calorie, high protein diet, as much as
50%above normal, should be encouraged. The impaired intestinal absorption can lead to
poor nutritional status. Additionally, the child should take supplementary pancreatic
enzymes to increase nutritional availability and reduce the waste product transit time
through the bowel.
Incorrect: Fat is expelled in stool as a result of poor fat absorption in the intestinal tract.
Incorrect: A high fiber diet is not a primary concern in the nutritional counseling for the child
with cystic fibrosis. A well-balanced diet that is high in protein and calories is necessary to
achieve growth.
Incorrect: A vegetarian diet is not encouraged unless it contains a high caloric density, high
protein and high fat components to meet the needs of the child with cystic fibrosis.
High calorie
Low fat
High fiber
Vegetarian
52 Which nursing assessment indicates bleeding in the postoperative phase after a tonsillectomy?
Correct: Frequent swallowing is an indication that the operative site is bleeding. Surgical
intervention or surgical packing may be needed.
Incorrect: Complaints of throat pain are common after surgery. Analgesic/antipyretic drugs, such
as acetaminophen or non-steroidal anti-inflammatory drugs (NSAID), are commonly
administered to promote comfort and reduce inflammation.
Incorrect: An increase in the pulse rate is common due to pain, stress, and physiologic response
to surgery.
Incorrect: Dark brown blood is commonly seen in the vomitus, secretions of the nose, and
between the teeth related to the blood loss during the surgical procedure. Active bleeding is
evidence by bright red blood or pink mucous. Oral intake is restricted until there are no signs of
hemorrhage.
Frequent swallowing
Complaints of throat pain
Increased pulse rate
Dark brown blood in the emesis
53 The school nurse provides an educational program for a group of preadolescents regarding the
use of birth control pills. Which is the mechanism of action for oral contraceptives?
Incorrect: Oral contraceptives do not kill sperm.
Correct: Oral contraceptives inhibit ovulation. If the ovum is not released from the ovary,
it cannot be fertilized and pregnancy cannot occur.
Incorrect: Oral contraceptives do not change the genetics of sperm.
Incorrect: Oral contraceptives do not interfere with the implantation of the fertilized ovum in the
uterus.
Kill sperm
Inhibit ovulation
Cause sperm dysfunction
Prevent ovum implantation
54 The mother of a school-aged child diagnosed with a terminal illness asks the nurse, “How
should I explain this to my child?” Which nursing instruction is most appropriate?
Incorrect: The child's physical condition may not determine how much information the child
understands or wants to know.
Incorrect: Although the school-aged child is in the Piaget's stage of concrete-operational thought,
photographs of other children in the latter stage of the disease may provide too much detail and
frighten him/her. This level of detail may be useful for health care professionals but not for an ill
child.
Incorrect: A full description of the disease process and contributing causes is probably more than
the child is interested in learning. The school-aged child is egocentric and the explanation needs
to pertain directly to the personal situation. Only information that is relevant to the child will be
retained.
Correct: The child's age, cognitive and emotional development set the boundaries
regarding the type and extent of information and the manner for delivery.
Provide an explanation of the illness depending on the child's physical condition.
Show photographs of the children in the latter phase of the disease.
Give a description of the disease process and contributing causes.
Explain the illness honestly at an age-appropriate level.
55 The nurse prepares to administer an intramuscular injection to a 4-year-old child. Which
site is most appropriate?
Incorrect: The ventrogluteal is not a recommended site for young children. The sciatic nerve can
be injured from a long needle injected posteriorly and medially.
Incorrect: The vastus lateralis is an acceptable site for intramuscular injection in preschool
children. However, often the site becomes sore and interferes with walking. The vastus lateralis
site is ideal for intramuscular injection in infancy and can be accessed in a variety of sitting,
lying or side-lying positions. This muscle can tolerate larger volumes of fluid because of the
development of the muscle mass in infancy.
Incorrect: The dorsogluteal is site that is frequently used for intramuscular injections in older
children and adults. The site is contraindicated in children walking less than one year.
Correct: The deltoid muscle is adequately developed in the preschool child and is likely to
tolerate the fluid in an intramuscular injection. From a developmental perspective, the
deltoid may be a more acceptable site for injection due to the sense of privacy that begins in
the preschool age group.
Ventrogluteal
Vastus lateralis
Dorsogluteal
Deltoid
56 Which is the peak age for the occurrence of sudden infant death syndrome (SIDS)?
Incorrect: Two to four weeks of age is early for most cases of SIDS. Unexplained death at this
time could be related to many types of congenital abnormalities, such as persistent, late apnea of
prematurity that exists beyond 44 weeks post-conceptual age.
Correct: The peak time period for the incidence of SIDS is two to four months of age with 95%
of the cases occurring by the age of six months. It is more common in low birth weight babies,
males, crowded living conditions, environmental cigarette smoke, and during the winter months.
Research indicates that infant positioning during sleep may be a factor in the incidence of SIDS.
Supine positioning for sleep in healthy infants is recommended to reduce the risk of SIDS.
Incorrect: By ten months of age, the risk for SIDS is markedly reduced. The infant has good
head, neck and back control. If an obstruction of the airway occurs as a result of head
positioning, the infant at 6-10 months of age can rescue him/herself.
Incorrect: After ten months of age, infant death is most likely to be the result of an accidental
injury.
Prior to four weeks
Two to six months
Six to ten months
After ten months
57 An adolescent seeks health care at a free clinic and states she is sexually active and concerned
about AIDS. Which nursing instruction regarding transmission of sexually transmitted diseases
is most appropriate?
Incorrect: Diaphragms do not prevent the transmission of infection. A diaphragm serves as a
barrier for the prevention of sperm penetration to the uterus. The diaphragm with spermicidal
agent is an effective method to reduce the chance of pregnancy, not the spread of infection.
Incorrect: The lack of symptoms of AIDS is unrelated to the infectious status as the virus may
lie dormant in the body for an extended period of time prior to the onset of symptoms of
infection.
Correct: Condoms are the best protection against the spread of sexually transmitted
disease (STD) if used correctly.
Incorrect: Spermicidal do not protect the body from the exposure to the virus.
“It is essential that you wear a diaphragm to prevent cross infection with your partner.”
“If your partner has no symptoms of sexually transmitted disease then you do not need to
worry.” “A condom is the best protection, except for abstinence, to prevent sexually transmitted
disease.” “A spermicidal is used to prevent the spread of sexually transmitted disease in both
partners.”
58 An adolescent girl is diagnosed with scoliosis and her mother is reluctant to pursue
treatment. The nurse educates the mother that untreated scoliosis may ultimately have which
outcome?
Incorrect: Scoliosis is not likely to correct over time.
Incorrect: Scoliosis of the thoracic region does not affect bladder control.
Incorrect: Scoliosis of the thoracic region does not affect gastrointestinal function.
Correct: Scoliosis is the lateral curvature of the spine, which may be congenital, idiopathic,
or a result of paralysis. Scoliosis is at the level of the chest, therefore, if untreated, heart
and lung function may be compromised.
Correct itself over time
Compromise bladder control
Reduce gastrointestinal function
Affect heart and lung performance
59 When assessing the heart rate for infants and small children, which pulse point should
the nurse use?
Correct: The apical pulse is recommended for infants and children and is heard at the
apex of the heart for one full minute.
Incorrect: The carotid pulse is located in the neck and is not used to assess heart rate in children.
Incorrect: Brachial pulses are used to assess the absence of a pulse when performing CPR.
Incorrect: Apical pulses are taken in children under one because the radial pulse rate is too faint.
Apical
Carotid
Brachial
Radial
60 A hospitalized 18-month-old is diagnosed with gastroenteritis. When providing
discharge teaching for the child's parents, which food should the nurse suggest be
reintroduced last?
Incorrect: Bananas can be introduced into the diet early and are part of the BRAT diet. Bananas
provide potassium, which may have been lost through vomiting and diarrhea.
Correct: Following an acute episode of gastroenteritis, foods are reintroduced slowly. The
glucose and milk within the pudding would be introduced later into the diet after the body
is able to tolerate the BRAT (Bananas, Rice, Applesauce and Toast) diet. The high sugar
and milk content found in the pudding may trigger further diarrhea.
Incorrect: Applesauce is a part of the BRAT diet and can be introduced into the diet early. It is
bland and easy to digest.
Incorrect: Rice is also part of the BRAT diet, is easily digested and can be introduced into the
diet early. Rice provides carbohydrates needed for energy.
Bananas
Pudding
Applesauce
Rice
61 A child with Type I diabetes mellitus experiences polyuria, polydipsia, and polyphagia,
and has a history of diabetic ketoacidosis. The family should be instructed that ketones can
appear in the urine when the blood glucose reaches which level?
Incorrect: 120 mg/dl is a normal blood glucose reading.
Correct: The normal blood glucose varies between 110-150 mg/dl. It is not until 250 mg/dl
that blood glucose will spill over into the urine.
Incorrect: 180 mg/dl is above normal limits but not far enough above normal limits for the
appearance of glucose in the urine.
Incorrect: 150 mg/dl is on the upper boundaries of normal but would not have any blood glucose
spilling to the urine.
120 mg/dl
250 mg/dl
180 mg/dl
150 mg/dl
62 A hospitalized preschool child is recovering from surgery and is in the playroom.
Which behavior should the nurse expect to observe?
Correct: An imaginary friend is not uncommon for this age. The creative imagination of a
preschool child is rapidly developing and acts as a way the child can practice social
relationships in a non-threatening environment. independent play activity among toddlers.
Playing a board game with another child
Talking to an imaginary friend
Throwing a ball into the air and catching it
Playing with a toy beside other children
63 A 4-week-old infant with an atrial septal defect (ASD) is monitored for signs of congestive
heart failure (CHF) prior to surgery. The nurse measures intake and output to determine the
fluid status of the child. Which is the best method to obtain an approximation of the volume of
urine output?
Correct: The correct procedure for the determination of an accurate urinary output is to
weigh the diaper prior to and following urination. Subtract the difference. Cloth diapers
vary in weight; a baseline measurement will be necessary. However, because the weight of
disposable diapers is stable with very little discrepancy among diaper weights, each diaper
does not need to be weighed but the baseline for that type and size is necessary information.
The conversion for volume to weight measurement is: 1cc = 1 gm.
Record the weight of the wet diaper directly on the graphic flow sheet.
After urination, weigh the wet diaper and divide by the birthweight.
Weigh the diaper before and after urination and subtract the difference.
Weigh the infant before and after urination and record the volume.
64 A 12-week-old infant requires the insertion of a ventricular peritoneal (VP) shunt for
the treatment of hydrocephalus. Which is the most serious complication of VP shunts?
Correct: Shunt infection is the most serious complication. Any type of invasive procedure
provides a risk of infection. Shunt infections are particularly grave since they may
compromise the intellect of the child.
Shunt migration
Obstruction of the shunt
Mechanical malfunction
Shunt infection
65 A mother brings her toddler into the clinic because of fussiness, fever, and pulling of the
right ear. The mother states that the symptoms are the same as when the child had a previous ear
infection. Which is the most appropriate nursing response?
Correct: The nurse explains the structure of the infant's ear and addresses the reason for
the infant's repeated ear infections.
"It is good that you are concerned because frequent ear infections may lead to deafness."
"It is probable that the previous ear infection did not completely resolve."
"Otitis media is an infection in the outer ear canal and is common in early childhood."
"Children are more prone to hear infections due to the shorter, straighter ear canal."
66 An 11-year-old receives an allergy shot during a clinic visit. Which symptom indicates
the early stage of anaphylactic shock?
Correct: A correlation has been found to relate reports of impending doom and
anxiousness and anaphylactic reactions. Incorrect: A heart rate of 90 beats per minute is
normal for a child that is eleven years old.
A blood pressure reading of
100/60 A sense of impending
doom
A heart rate of 90
Complaints of abdominal cramping
67 When initiating a plan of care for the child with leukemia, the nurse informs the family
to anticipate which diagnostic test?
Correct: The test commonly used to diagnose leukemia is a bone marrow aspiration.
Leukemia is the uncontrolled production of white blood cells, and is the most frequently
occurring type of cancer in children. The bone marrow of the client is characterized by a
high white blood cell count (leukocytosis), low platelet count (thrombocytopenia) and
immature white blood cells (blast cells.)
Red blood cell count
Positron Emission Tomography
(PET) Bone marrow aspiration
Blood gas analysis
68 The administration of aspirin has been discouraged in pediatric use because of the association
of which condition?
Correct: Aspirin should not be given to children with influenza virus or chickenpox due to
the association with Reye's Syndrome. This disorder is characterized by encephalopathy
and liver dysfunction.
Erb palsy
Hodgkin's disease
Kaposi sarcoma
Reye's syndrome
69 A child diagnosed with sickle cell disease experiences an acute, vasoocclusive crisis.
Which nursing intervention is the priority?
Correct: The priority for the care of the child with acute vasoocclusive crisis is oxygen
therapy. Sickled cells cause obstruction in the blood vessels leading to tissue ischemia and
infarction.
Maintain hydration.
Prevent infection.
Provide analgesia.
Administer oxygen.
70 The nurse provides discharge instructions to the parent of a child who has a newly applied
cast to the leg. Which statement by the parent indicates the need for further nursing
instruction?
Correct: The palms of the hands should be used when handling the wet cast to prevent
depressions to the external surface
"The new cast will need to air dry."
"I should use my fingertips when handling the wet cast."
"I need to check the toes for temperature and color."
"I will place the leg above the level of the heart."
71 Which is the main difference between the male and female anatomy related to urinary
tract infections?
Correct: The urethra is shorter and straighter in females; therefore, pathogens can enter
the bladder more readily. Due to the proximity of the rectum, the female urethra may be
more easily contaminated with bacteria. The nurse can provide education to the child
and/or caregiver to practice hygiene measures to reduce the spread of organisms to the
genitourinary tract. Incorrect: Both the male and female tracts are lined with mucous
membranes.
The male urethra is straighter, allowing more rapid elimination of pathogens.
The female urethra is shorter so the pathogens can enter the bladder more quickly.
The male urethra is lined with mucous membranes to trap microorganisms.
The female urethra is larger in diameter, allowing for the rapid entrance of pathogens.
72 A teenage boy commits suicide. Which is the main cause of suicide?
Correct: Suicide is most commonly referred to as destructive aggression turned inward
against the self.
An act of defiance
A psychotic act
Destructive aggression turned inward
A form of manipulation
73 Which signs indicate IV infiltration in a child?
Correct: Erythema (redness), pain, edema and a streaking at the vein site are indications
that IV fluids may be accumulating in the interstitial tissue and not going through the
circulation. Also these signs may indicate an irritation of the vein that could cause IV
compromise.
Fever, chills, and pain
Erythema, edema, and streaking at the vein site
Limited ability to move the extremity
Backflow of blood at the IV site and in the IV tubing
74 Following the surgical repair of a toddler's cleft palate, which method of administering fluid
is most appropriate in the post-operative recovery period?
Correct: Nothing should be placed inside of the mouth as palate sutures may be damaged.
A cleft palate is typically repaired between 12-18 months of age. It is important to offer
the cup in a manner that is appropriate for the skills of toddler age.
Sippy cup
Drinking straw
Regular cup
Breck feeder
75 The nurse planning the care for a child that has partial and full thickness burns
understands that an early complication with extensive burns is
Correct: The primary emphasis during the initial phase of burn care is the prevention of
hypovolemic shock.
dehydration.
infection.
hypovolemic shock.
high-output renal failure.
